Look away now! Defensive processing and unrealistic optimism by level of alcohol consumption

OBJECTIVE

Health risk information is insufficient as a means of reducing alcohol use, particularly when it evokes negative emotional states amongst those for whom it is most personally relevant. Appraisal biases, or 'defensive processing', may be employed to mitigate the psychological discomfort posed by such information. Few studies have evaluated the role of defensive processing in people with different levels of alcohol consumption.

DESIGN

Online participants (n = 597) completed measures of defensive processing of a health risk infographic, perceived susceptibility and severity of alcohol use, efficacy for resisting alcohol use, unrealistic optimism, the Alcohol Use Disorder Identification Test - Consumption (AUDIT-C) and demographics.

RESULTS

AUDIT-C scores were positively and linearly associated with all defensive processing measures (Pearson's correlation r from.16 to .36), threat and susceptibility (r = .16) and unrealistic optimism (r = .50). AUDIT-C scores were also negatively associated with efficacy for controlling alcohol use (r = -0.48).

CONCLUSION

People with alcohol use disorder (AUD) engaged in much more defensive processing of alcohol-related messages, offering an explanation for why such messages are limited at eliciting behaviour change. High levels of unrealistic optimism in people with alcohol use disorder may reflect low problem recognition in order to maintain a problem-free drinking identity.

Neurodevelopmental outcomes in children and adults with Fetal Valproate Spectrum Disorder: A contribution from the ConcePTION project

AIM

To describe the neurodevelopmental phenotype of older children and adults with a diagnosis of Fetal Valproate Spectrum Disorder (FVSD).

METHODS

In this cross-sectional study, 90 caregivers were recruited and completed a series of questionnaires regarding the neurodevelopmental outcomes of 146 individuals aged 7-37 years (M = 18.1), including individuals with a formal diagnosis of FVSD (n = 99), individuals exposed to Valproate but without an FVSD diagnosis (n = 24), and individuals not exposed to Valproate (N = 23). The mean dose of valproate exposure for individuals with an FVSD diagnosis was 1470 mg/day.

RESULTS

Individuals with a diagnosis of FVSD showed significantly higher levels of moderate (43.4%) and severe (14.4%) cognitive impairment than other groups (p = 0.003), high levels of required formal educational support (77.6%), and poorer academic competence than individuals not exposed to Valproate (p = 0.001). Overall psychosocial problems (p = 0.02), internalising problems (p = 0.05) and attention problems (p = 0.001), but not externalising problems, were elevated in individuals with a diagnosis of FVSD. Rates of neurodevelopmental disorders, particularly autistic spectrum disorders (62.9%) and sensory problems (80.6%) are particularly central to the FVSD phenotype. There was no evidence of a statistical dose-dependent effect, possibly due to the high mean dose of exposure having a uniformly negative impact across the sample. Individuals with FVSD had required a significant number of health and child development services.

INTERPRETATION

Children and young adults with a diagnosis of FVSD are at an increased risk of a range of altered neurodevelopmental outcomes, highlighting the need for a multidisciplinary approach to clinical management across the lifespan.

Should we promote alcohol problems as a continuum? Implications for policy and practice

The highly heterogeneous nature of alcohol use and problems has presented significant challenges to those attempting to understand, treat or prevent what is commonly termed alcohol use disorder (AUD). However, any attempts to capture this complex phenomenon, including the various current criterion of AUD, come with a number of limitations. One particular limitation has been how alcohol problems are represented or understood in ways which do not capture the broad spectrum of alcohol use and harms and the many potential routes to prevention, treatment, and recovery. One possible response to this has been proposed as more explicitly framing or conceptualizing a continuum model of alcohol use and harms. In this commentary, we attempt to identify the key implications of a continuum model for policy and practice, examining the historical and current context of alcohol problem classifications and models. We argue a continuum model of alcohol use and problems holds a number of advantages for advancing public health goals, but also some potential limitations, both of which require further examination.

The "alcoholic other": Harmful drinkers resist problem recognition to manage identity threat

OBJECTIVE

Harmful drinkers represent an important Alcohol Use Disorder (AUD) group in public health terms, accounting for significant health and social costs. However, harmful drinkers are characterized by low problem recognition; they tend to construct their drinking identity as positive and problem-free, actively setting themselves apart from the stigmatised 'alcoholic other'. As such, harmful drinkers rarely engage in treatment and represent an important opportunity for lower threshold interventions and self-change. The present study sought to explore AUD problem framing and stigma effects on problem recognition.

METHODS

Harmful drinkers without perceived addiction experience recruited online (n = 244, 54% male, 46% female, 96% British) were randomised to one of six conditions comprising beliefs about alcohol problems (control, continuum, binary disease model) and stigma (stigma, non-stigma), and completed measures relating to problem recognition.

RESULTS

As predicted, results found that harmful drinkers exposed to binary disease model beliefs and stigmatising language had significantly lower problem recognition than those in other conditions. However, no support was found for the prediction that continuum beliefs would be associated with higher problem recognition. Results suggest that the interaction of binary disease model beliefs and stigma prompted alcoholic label avoidance.

CONCLUSION

These findings suggest that problem framing has important consequences for harmful drinkers. Implications for behaviour change amongst harmful drinkers through mechanisms of problem framing and identity are discussed.

Chemical Exposure-Induced Developmental Neurotoxicity in Head-Regenerating Schmidtea Mediterranea

The growing number of commercially-used chemicals that are under-evaluated for developmental neurotoxicity (DNT) combined with the difficulty in describing the etiology of exposure-related neurodevelopmental toxicity has created a reticent threat to human health. Current means of screening chemicals for DNT are limited to expensive, time-consuming, and labor-intensive traditional laboratory animal models. In this study, we hypothesize that exposed head regenerating planarian flatworms can effectively and efficiently categorize DNT in known developmental neurotoxins (ethanol and bisphenol A (BPA)). Planarian flatworms are an established alternative animal model for neurodevelopmental studies and have remarkable regenerative abilities allowing neurodevelopment to be induced via head resection. Here, we observed changes in photophobic behavior and central nervous system (CNS) morphology to evaluate the impact of exposure to low concentrations of ethanol, BPA, and BPA industry alternatives bisphenol F (BPF), and bisguaiacol (BG) on neurodevelopment. Our studies show that exposure to 1% v/v ethanol during regeneration induces a recoverable 48-hour delay in the development of proper CNS integrity, which aligns with behavioral assessments of cognitive ability. Exposure to BPA and its alternatives induced deviations to neurodevelopment in a range of severities, distinguished by suppressions, delays, or a combination of the two. These results suggest that quick and inexpensive behavioral assessments are a viable surrogate for tedious and costly immunostaining studies, equipping more utility and resolution to the planarian model for neurodevelopmental toxicity in the future of mass chemical screening. These studies demonstrate that behavioral phenotypes observed following chemical exposure are classifiable and also temporally correlated to the anatomical development of the central nervous system in planaria. This will facilitate and accelerate toxicological screening assays with this alternative animal model.

55 Are Virtual Journal Clubs A Viable Alternative in The Covid-19 Era?

Introduction

During the COVID-19 pandemic, face to face journal clubs have been curtailed due to Governmental guidance for social distancing. We present an example of a virtual journal club set up for Orthopaedic senior house officers (SHOs) & trainees in the North West Thames (NWT) Deanery from April to August 2020.

Method

Our aims were to establish a regular online journal club for orthopaedic trainees in NWT that successfully met the objectives of the more established face to face meetings. Assessment of each session was evaluated using a post attendance survey created using an established online generator.

Results

64.4% (16/25 participants) had not attended a virtual journal club before, with 100% (33/33) reporting that they would attend another virtual journal club. 39.4% (13/33) of attendees agreed or strongly agreed that they could participate in sessions over more conventional meetings. 24.2% (8/33) of participants reported experiencing technical issues during the sessions. 90.9% (30/33) of respondents reporting the virtual model to be more convenient than standard journal clubs.

Conclusions

The potential benefits of significantly increased accessibility increased visiting expert contribution whilst still adhering to government guidelines; weighed against marginally less effective teaching nonetheless results in an overall benefit.

Implementation and evaluation of a quality improvement initiative to reduce late gestation stillbirths in Australia: Safer Baby Bundle study protocol

BACKGROUND

In 2015, the stillbirth rate after 28 weeks (late gestation) in Australia was 35% higher than countries with the lowest rates globally. Reductions in late gestation stillbirth rates have steadily improved in Australia. However, to amplify and sustain reductions, more needs to be done to reduce practice variation and address sub-optimal care. Implementing bundles for maternity care improvement in the UK have been associated with a 20% reduction in stillbirth rates. A similar approach is underway in Australia; the Safer Baby Bundle (SBB) with five elements: 1) supporting women to stop smoking in pregnancy, 2) improving detection and management of fetal growth restriction, 3) raising awareness and improving care for women with decreased fetal movements, 4) improving awareness of maternal safe going-to-sleep position in late pregnancy, 5) improving decision making about the timing of birth for women with risk factors for stillbirth.

METHODS

This is a mixed-methods study of maternity services across three Australian states; Queensland, Victoria and New South Wales. The study includes evaluation of 'targeted' implementer sites (combined total approximately 113,000 births annually, 50% of births in these states) and monitoring of key outcomes state-wide across all maternity services. Progressive implementation over 2.5 years, managed by state Departments of Health, commenced from mid-2019. This study will determine the impact of implementing the SBB on maternity services and perinatal outcomes, specifically for reducing late gestation stillbirth. Comprehensive process, impact, and outcome evaluations will be conducted using routinely collected perinatal data, pre- and post- implementation surveys, clinical audits, focus group discussions and interviews. Evaluations explore the views and experiences of clinicians embedding the SBB into routine practice as well as women's experience with care and the acceptability of the initiative.

DISCUSSION

This protocol describes the evaluation of the SBB initiative and will provide evidence for the value of a systematic, but pragmatic, approach to strategies to reduce the evidence-practice gaps across maternity services. We hypothesise successful implementation and uptake across three Australian states (amplified nationally) will be effective in reducing late gestation stillbirths to that of the best performing countries globally, equating to at least 150 lives saved annually.

TRIAL REGISTRATION

The Safer Baby Bundle Study was retrospectively registered on the ACTRN12619001777189 database, date assigned 16/12/2019.

Effects on health and process outcomes of physiotherapist-led orthopaedic triage for patients with musculoskeletal disorders: a systematic review of comparative studies

BACKGROUND

Physiotherapist-led (PT-led) orthopaedic triage is an evolving model of care for patients with musculoskeletal disorders. Objectives for this study were to establish the current evidence body on the impact of PT-led orthopaedic triage on health, quality, and service outcomes for patients referred for orthopaedic consultation, compared with standard (orthopaedic surgeon) care.

METHODS

Medline, EMBASE, Scopus and CINAHL were searched from inception until 7 May 2018; search updated 24 April 2020. Search terms (including derivatives) included physiotherapy, advanced/extended scope, musculoskeletal/orthopaedic, triage. The search was framed as Population = patients referred for orthopaedic consultation; Intervention = PT-led orthopaedic triage; Comparison = standard care; Outcomes = health, quality and process outcomes. Only randomised controlled trials (RCTs) and prospective comparative cohort studies were eligible for inclusion. Screening, study selection, data extraction, and assessment of methodological quality were performed independently by reviewer pairs. Quality was scored with the Downs and Black checklist. Certainty of evidence was determined using GRADE. PROSPERO registration number CRD42017070950.

RESULTS

We included two RCTs and eleven cohort studies (n = 1357 participants) of variable methodological quality (range 14-23 of possible 28). Certainty of evidence was low to moderate. There was no difference between PT-led orthopaedic triage and standard care for patient-reported outcomes (two RCTs). Perceived quality of care with PT-led orthopaedic triage was higher (two RCTs, four cohort studies) or equal (one cohort study) compared with standard care. PT-led orthopaedic triage had higher surgery conversion rates (one RCT, three cohort studies) (55-91% vs 22-38%), lower (two RCTs) or equal rate (two cohort studies) of referral for investigations, shorter waiting times (one RCT, one cohort study), and lower costs (one RCT). Furthermore, there was high agreement between physiotherapists' and orthopaedic surgeons' treatment approach (eight cohort studies), referral for investigation (five cohort studies), and diagnosis (nine cohort studies). Study limitations were the low number of RCTs, and variable methodological quality.

CONCLUSIONS

Evidence of low to moderate certainty suggests that PT-led orthopaedic triage leads to similar diagnostic decisions as standard care, has a higher conversion-to-surgery rate, reduces waiting times, is cost effective and valued by patients, and that health outcomes are equivalent.

A composite neonatal adverse outcome indicator using population-based data: an update

Introduction

Severe morbidity rates in neonates can be estimated using diagnosis and procedure coding in linked routinely collected retrospective data as a cost-effective way to monitor quality and safety of perinatal services. Coding changes necessitate an update to the previously published composite neonatal adverse outcome indicator for identifying infants with severe or medically significant morbidity.

Objectives

To update the neonatal adverse outcome indicator for identifying neonates with severe or medically significant morbidity, and to investigate the validity of the updated indicator.

Methods

We audited diagnosis and procedure codes and used expert clinician input to update the components of the indicator. We used linked birth, hospital and death data for neonates born alive at 24 weeks or more in New South Wales, Australia (2002–2014) to describe the incidence of neonatal morbidity and assess the validity of the updated indicator.

Results

The updated indicator included 28 diagnostic and procedure components. In our population of 1,194,681 live births, 5.44% neonates had some form of morbidity. The rate of morbidity was greater for higher-risk pregnancies and was lowest for those born at 39–40 weeks’ gestation. Incidence increased over the study period for overall neonatal morbidity, and for individual components: intravenous infusion, respiratory diagnoses, and non-invasive ventilation. Severe or medically significant neonatal morbidity was associated with double the risk of hospital readmission and 10 times the risk of death within the first year of life.

Conclusion

The updated composite indicator has maintained concurrent and predictive validity and is a standardised, economic way to measure neonatal morbidity when using population-based data. Changes within individual components should be considered when examining longitudinal data.

Use of public water supply fluoride concentration as an indicator of population exposure to fluoride in England 1995-2015

Public health monitoring of Community Water Fluoridation (CWF) schemes requires estimates of exposure to fluoride in public water supplies (PWS). We aimed to use routine data to estimate population exposure to PWS-fluoride in England and to determine whether PWS-fluoride exposure from 2005 to 2015 could be used as a proxy for exposure for 1995-2004, when fluoride concentration data that could be linked to population health data were unavailable. We calculated annual mean water supply zone PWS-fluoride concentrations from monitoring data for 1995-2015, stratified by fluoridation scheme-flagging. We allocated annual 2005-2015 mean PWS-fluoride concentrations to small area boundaries to describe population exposure within five concentration categories (< 0.1 to ≥ 0.7 mg/L). We compared zone-level 1995-2004 and 2005-2015 mean PWS-fluoride concentrations using Spearman correlation. Most (72%) of the population received PWS with < 0.2 mg/L fluoride and 10% with ≥ 0.7 mg/L. Fluoride concentrations in 1995-2004 and 2005-2015 were similar (median 0.11 mg/L (lower quartile-upper quartile (LQ-UQ) 0.06-0.17) and 0.11 mg/L (LQ-UQ 0.07-0.17), respectively) and highly correlated (coefficient 0.93) if un-fluoridated but differed (1995-2004 median 0.78 mg/L (LQ-UQ 0.59-0.92); 2005-2015 0.84 mg/L (LQ-UQ 0.72-0.95)) and correlated weakly (coefficient 0.31) if fluoridated. Fluoride concentrations in 2005-2015 approximate those in 1995-2004 but with a greater risk of misclassification in fluoridation schemes.

Immunogenicity of the hepatitis A vaccine 20 years after infant immunization

To determine the duration of immunity provided by the Hepatitis A vaccination (HepA), we evaluated a cohort of participants in Alaska 20 years after being immunized as infants. At recruitment, participants received two doses of inactivated HepA vaccine on one of three schedules. We conducted hepatitis A antibody (anti-HAV) testing for participants at the 20-year time-point. Seventy-five of the original 183 participants (41%) were available for follow-up. The overall anti-HAV geometric mean concentration was 29.9 mIU/mL (95% CI 22.4 mIU/mL, 39.7 mIU/mL) and 50 participants (68%) remained seropositive (titer ≥ 20 mIU/mL). Using a fractional polynomial model, the predicted percent seropositive at 25 years was 55.3%, 49.8% at 30 years and 45.7% at 35 years, suggesting that the percent sero-positive could drop below 50% earlier than previously expected. Further research is necessary to understand if protection continues after seropositivity diminishes or if a HepA booster dose may become necessary.

Continuum beliefs are associated with higher problem recognition than binary beliefs among harmful drinkers without addiction experience

Low problem recognition may be an important barrier to opportunities for self-change or help-seeking in harmful drinkers. Little is known about how the beliefs harmful drinkers hold about the nature and causes of alcohol problems affect problem recognition and subsequent behaviour change processes. Participants (n = 597) recruited online were randomised to one of two conditions designed to promote beliefs according to (a) a continuum model of alcohol problems or (b) a binary disease model, or (c) a control condition. Participants completed measures of alcohol problem beliefs, problem recognition and other indices including the Alcohol Use Disorder Identification Test (AUDIT), addiction beliefs, addiction experience and demographics. Results showed that harmful drinkers without addiction experience exposed to the continuum condition had significantly higher problem recognition than those in binary disease model or control conditions. Continuum beliefs appear to offer self-evaluative benefits for harmful drinkers with low alcohol problem recognition, thus potentially facilitating help-seeking or self-change regarding alcohol use. Further research to understand the mechanisms by which continuum beliefs may promote more accurate drinking self-evaluation and its potential for behaviour change is warranted. The role of continuum beliefs may have important consequences for alcohol-related messaging and interventions seeking to promote self-change or help-seeking.

Editorial - Child oral health; is there anything more to know?

It seems a strange thing to be writing about child oral health in the middle of a virus pandemic that has, in the UK at least, paused all routine dental care. Perhaps not; as thoughts turn to the return of "normal" opera- tion there are concerns over potential ongoing impacts from COVID-19 on health services including stricter infection-control requirements and economic impacts from the lockdown. It invites ridicule to try and predict what will happen in the coming years, but the economic and social impacts are likely to increase vulnerability among the already vulnerable and the delivery of dental care is likely to be more problematic and more expensive. More than ever we need to reduce the burden of avoidable dental disease.

Greater child dental health inequality in England compared to Wales and Northern Ireland, despite lower average disease levels

INTRODUCTION

Dental caries and inequalities in dental health are major public health concerns.

AIM

To report variation in dental caries experience across deprivation quintiles and the magnitude of inequalities between countries.

DESIGN

Secondary analyses of cross-sectional data from the 2013 Child Dental Health Survey (CDHS) in England, Wales, and Northern Ireland.

MATERIALS AND METHODS

Distribution of dental caries across deprivation quintiles were estimated using as proportions and means. The magnitude of inequalities was calculated using the Relative Index of Inequality (RII).

MAIN OUTCOMES

Dental caries experience as indicated by the prevalence (%dmft/DMFT>0) and severity (dmft/DMFT) of 'obvious' and 'clinical' decay experience in both primary and permanent dentitions.

RESULTS

Children from more deprived quintiles showed higher prevalence and severity of dental caries. RIIs for dental caries were greater in England than Wales or Northern Ireland, indicating greater relative inequalities despite lower average dental caries experience. The prevalence and severity of dental caries among the most deprived children in England were 1.7 to 3.7 times greater than those of the least deprived.

CONCLUSION

There is a deprivation gradient in child dental caries in all three countries, with England showing the greatest inequalities.

Survey of Australian maternity hospitals to inform development and implementation of a stillbirth prevention 'bundle of care'

BACKGROUND

'Bundles of care' are being implemented to improve key practice gaps in perinatal care. As part of our development of a stillbirth prevention bundle, we consulted with Australian maternity care providers.

OBJECTIVE

To gain the insights of Australian maternity care providers to inform the development and implementation of a bundle of care for stillbirth prevention.

METHODS

A 2018 on-line survey of hospitals providing maternity services included 55 questions incorporating multiple choice, Likert items and open text. A senior clinician at each site completed the survey. The survey asked questions about practices related to fetal growth restriction, decreased fetal movements, smoking cessation, intrapartum fetal monitoring, maternal sleep position and perinatal mortality audit. The objectives were to assess which elements of care were most valued; best practice frequency; and, barriers and enablers to implementation.

RESULTS

227 hospitals were invited with 83 (37%) responding. All proposed elements were perceived as important. Hospitals were least likely to follow best practice recommendations "all the time" for smoking cessation support (<50%), risk assessment for fetal growth restriction (<40%) and advice on sleep position (<20%). Time constraints, absence of clear guidelines and lack of continuity of carer were recognised as barriers to implementation across care practices.

CONCLUSIONS

Areas for practice improvement were evident. All elements of care were valued, with increasing awareness of safe sleeping position perceived as less important. There is strong support from maternity care providers across Australia for a bundle of care to reduce stillbirth.

Phase II study of nab-paclitaxel in refractory small bowel adenocarcinoma and CpG island methylator phenotype (CIMP)-high colorectal cancer

Background

Hypermethylation of promoter CpG islands [CpG island methylator phenotype (CIMP)] represents a unique pathway for the development of colorectal cancer (CRC), characterized by lack of chromosomal instability and a low rate of adenomatous polyposis coli (APC) mutations, which have both been correlated with taxane resistance. Similarly, small bowel adenocarcinoma (SBA), a rare tumor, also has a low rate of APC mutations. This phase II study evaluated taxane sensitivity in SBA and CIMP-high CRC.

Patients and methods

The primary objective was Response Evaluation Criteria in Solid Tumors version 1.1 response rate. Eligibility included Eastern Cooperative Oncology Group performance status 0/1, refractory disease, and SBA or CIMP-high metastatic CRC. Nab-paclitaxel was initially administered at a dose of 260 mg/m2 every 3 weeks but was reduced to 220 mg/m2 owing to toxicity.

Results

A total of 21 patients with CIMP-high CRC and 13 with SBA were enrolled from November 2012 to October 2014. The efficacy-assessable population (patients who received at least three doses of the treatment) comprised 15 CIMP-high CRC patients and 10 SBA patients. Common grade 3 or 4 toxicities were fatigue (12%), neutropenia (9%), febrile neutropenia (9%), dehydration (6%), and thrombocytopenia (6%). No responses were seen in the CIMP-high CRC cohort and two partial responses were seen in the SBA cohort. Median progression-free survival was significantly greater in the SBA cohort than in the CIMP-high CRC cohort (3.2 months compared with 2.1 months, P = 0.03). Neither APC mutation status nor CHFR methylation status correlated with efficacy in the CIMP-high CRC cohort. In vivo testing of paclitaxel in an SBA patient-derived xenograft validated the activity of taxanes in this disease type.

Conclusion

Although preclinical studies suggested taxane sensitivity was associated with chromosomal stability and wild-type APC, we found that nab-paclitaxel was inactive in CIMP-high metastatic CRC. Nab-paclitaxel may represent a novel therapeutic option for SBA.

STRIDER NZAus: a multicentre randomised controlled trial of sildenafil therapy in early-onset fetal growth restriction

OBJECTIVE

To assess the effect of maternal sildenafil therapy on fetal growth in pregnancies with early-onset fetal growth restriction.

DESIGN

A randomised placebo-controlled trial.

SETTING

Thirteen maternal-fetal medicine units across New Zealand and Australia.

POPULATION

Women with singleton pregnancies affected by fetal growth restriction at 22⁺⁰ to 29⁺⁶ weeks.

METHODS

Women were randomised to oral administration of 25 mg sildenafil citrate or visually matching placebo three times daily until 32⁺⁰ weeks, birth or fetal death (whichever occurred first).

MAIN OUTCOME MEASURES

The primary outcome was the proportion of pregnancies with an increase in fetal growth velocity. Secondary outcomes included live birth, survival to hospital discharge free of major neonatal morbidity and pre-eclampsia.

RESULTS

Sildenafil did not affect the proportion of pregnancies with an increase in fetal growth velocity; 32/61 (52.5%) sildenafil-treated, 39/57 (68.4%) placebo-treated [adjusted odds ratio (OR) 0.49, 95% CI 0.23-1.05] and had no effect on abdominal circumference Z-scores (P = 0.61). Sildenafil use was associated with a lower mean uterine artery pulsatility index after 48 hours of treatment (1.56 versus 1.81; P = 0.02). The live birth rate was 56/63 (88.9%) for sildenafil-treated and 47/59 (79.7%) for placebo-treated (adjusted OR 2.50, 95% CI 0.80-7.79); survival to hospital discharge free of major neonatal morbidity was 42/63 (66.7%) for sildenafil-treated and 33/59 (55.9%) for placebo-treated (adjusted OR 1.93, 95% CI 0.84-4.45); and new-onset pre-eclampsia was 9/51 (17.7%) for sildenafil-treated and 14/55 (25.5%) for placebo-treated (OR 0.67, 95% CI 0.26-1.75).

CONCLUSIONS

Maternal sildenafil use had no effect on fetal growth velocity. Prospectively planned meta-analyses will determine whether sildenafil exerts other effects on maternal and fetal/neonatal wellbeing.

TWEETABLE ABSTRACT

Maternal sildenafil use has no beneficial effect on growth in early-onset FGR, but also no evidence of harm.

Impact of social deprivation, demographics and centre on HbA1c outcomes with continuous subcutaneous insulin infusion

AIMS

To assess the impact of social deprivation, demographics and centre on HbA_1c outcomes with continuous subcutaneous insulin infusion (CSII) in adults with Type 1 diabetes.

METHODS

Demographic data, postcode-derived English Index of Multiple Deprivation data and 12-month average HbA_1c (mmol/mol) pre- and post-CSII were collated from three diabetes centres in the north west of England, University Hospital of South Manchester (UHSM), Salford Royal Foundation Hospital (SRFT) and Manchester Royal Infirmary (MRI). Univariable and multivariable regression models explored relationships between demographics, Index of Multiple Deprivation, centre and HbA_1c outcomes.

RESULTS

Data were available for 693 (78%) individuals (UHSM, n = 90; SRFT, n = 112; and MRI, n = 491) of whom 59% were women. Median age at CSII start was 39 (IQR 29.5-49.0) years and median diabetes duration was 20 (11-29) years. Median Index of Multiple Deprivation was 15 193 (6313-25 727). Overall median HbA_1c improved from 69 to 64 mmol/mol (8.5% to 8.0%) within the first year of CSII. In multivariable analysis, higher pre-CSII HbA_1c was significantly associated with higher deprivation (P = 0.036), being female (P < 0.001), and centre (MRI; P = 0.005). Following pre-CSII HbA_1c adjustment, post-CSII HbA_1c or HbA_1c change were not related to demographic factors and deprivation, but remained significantly related to the centre; UHSM and SRFT had larger reductions in HbA_1c with CSII compared with MRI [median -7.0 (-0.6%) vs. -6.0 (-0.55%) vs. -4.5 (-0.45%) mmol/mol; P = 0.005].

CONCLUSIONS

Higher pre-CSII HbA_1c levels were associated with higher deprivation and being female. CSII improves HbA_1c irrespective of social deprivation and demographics. Significant differences in HbA_1c improvements were observed between centres. Further work is warranted to explain these differences and minimize variation in clinical outcomes with CSII.

Abstract P1-11-05: Withdrawn

This abstract was withdrawn by the authors.

Citation Format: Bundred NJ, Foden P, Riches K, Morris J, Evans A, Todd C, Bramley M, Skene A, Watterson D, Purushotham A, Keeley V. Withdrawn [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P1-11-05.

Abstract P3-03-42: Withdrawn

This abstract was withdrawn by the authors.

Citation Format: Bundred NJ, Foden P, Riches K, Morris J, Evans A, Todd C, Bramley M, Skene A, Purushotham A, Keeley V. Withdrawn [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P3-03-42.

Abstract P2-07-01: Prediction model for lymphoedema, and effect of Lymphoedema diagnosis on quality of life (QoL) and distant recurrence from breast cancer

Introduction

Lymphoedema develops after surgery in 30% patients. In a prospective, multi-centre UK study, we used a validated perometer arm measurement to determine 1) the factors predicting lymphoedema development and 2) the effect of a lymphoedema diagnosis on QoL and survival.

Methods

Participants (n = 1100) undergoing axillary clearance at 9 centres underwent arm volume measurements pre and post-surgery by perometry, and completed FACT-B+4 and Lymphoedema checklist questionnaires. Relative arm volume increase (RAVI) of &gt;10% diagnosed lymphoedema. Predictors of lymphoedema development were determined using logistic regression, and changes in QoL were assessed using Generalised Estimating Equation (GEE) analyses.

Results

Median patient age was 56 (range 22 to 90) years; 78% received radiotherapy and 65% chemotherapy. Lymphoedema was detected in 21.4% of women by perometry and 24.4% underwent sleeve application by 24 months.

Initial decreases in QoL scores post-surgery were greater in patients with lymphoedema and took longer to return to baseline values (FACT-B p=0.014, TOI p=0.008, ARM subscale p&lt;0.001).

RAVI at 1 month (p&lt;0.001), BMI in three categories (≤25, &gt;25-≤30 and &gt;30, p=0.05), ER status (p=0.05) and number of positive nodes (p&lt;0.001) were used to develop a novel scoring model (AUROC 0.80) to predict lymphoedema. Out of 826 patients used for the model, 75% of patients had low scores (≤1) at 1 month and 11.6% developed lymphoedema by 24 months, whereas 20% who scored moderate risk (1.5-2) had a 31.3% risk and 5% who scored high risk (2.5-4) and had a 66.7% risk. Using the model scores, 75% of patients could be reassured regarding their lymphoedema risk.

Local recurrence was 1.7%. One hundred and twenty-nine patients had died of breast cancer (n=88) or had distant recurrence (n=41) across the study.

Lymphoedema (RAVI≥10%) by 9 months was an independent predictor of post 9 months distant disease-free cancer survival (Table).

Distant Disease Free Survival (DDFS) after Lymphoedema diagnosis Single variableMultivariableVariable (between 3 and 9 months)nHazard ratio (HR) (95% CI)p-valueHR (95% CI)p-valueRAVI ≥ 10% Yes: 105 vs No9552.30 (1.39-3.81)0.0011.73 (1.01-2.96)0.047ER Status Negative: 1719532.94 (1.92-4.49)&lt;0.0011.734 (1.06-2.83)0.028No. positive nodes*9691.07 (1.05-1.09)&lt;0.0011.05 (1.03-1.08)&lt;0.001Adjuvant CT Yes: 654 vs No9630.83 (0.54-1.27)0.390.60 (0.37-0.964)0.035Hormone treatment Yes: 808 vs No9640.45 (0.28-0.72)0.001--Tumour size*9591.02 (1.01-1.024)&lt;0.0011.02 (1.01-1.03)&lt;0.001Grade     0/1: 679611 (-)&lt;0.0011 (-)&lt;0.0012: 428 3.96 (0.54-29.324) 2.69 (0.36-20.33) 3: 436 11.59 (1.61-83.54) 6.91 (0.94-50.90) Undiff: 30 17.58 (2.12-146.184) 12.54 (1.43-109.96) *Per unit increase

Conclusions

Lymphoedema is associated with lasting quality of life deficits and early distant relapse.

Women at low risk of lymphoedema (75%) can be reassured using the scoring model. Early Arm measurements at 1 month post-surgery a useful measurement time to determine lymphoedema risk and enable patients to be reassured (75%) or plan for lymphoedema monitoring.

Citation Format: Bundred NJ, Foden P, Riches K, Morris J, Evans A, Todd C, Bramley M, Skene A, Purushotham A, Keeley V. Prediction model for lymphoedema, and effect of Lymphoedema diagnosis on quality of life (QoL) and distant recurrence from breast cancer [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P2-07-01.

A Randomized Study Comparing the Incidence of Postoperative Pain After Phrenic Nerve Infiltration Vs Nonphrenic Nerve Infiltration During Thoracotomy

Thoracotomy is a common surgical procedure performed worldwide for lung disease. Despite major advances in analgesia, patients still experience severe shoulder, central back and surgical incision site pain in the postoperative period. This study aimed to assess whether intraoperative phrenic nerve infiltration reduces the incidence of postoperative pain and improves peak flow volume measurements during incentive spirometry. 90 patients undergoing open lobectomy were randomly assigned to have phrenic nerve infiltration (n = 46) or not (n = 44). The phrenic nerve infiltration group received 10 mL of 0.25% bupivacaine into the periphrenic fat pad. Preoperative assessments of spirometry and pain scores were recorded (at rest and with movement). Postoperative assessments included peak flow and pain measurements at intervals up to 72 hours. Less shoulder pain was experienced with phrenic nerve infiltration up to 6 hours postsurgery at rest (P = 0.005) and up to 12 hours with movement (P < 0.001). Reduced back pain was reported in the phrenic nerve infiltration group up to 6 hours after surgery both at rest (P = 0.001) and with movement (P = 0.00). Phrenic nerve infiltration reduced pain at the incision site for up to 3 hours both at rest (P < 0.001) and with movement (P = 0.001). Spirometry readings dropped in both groups with consistently lower readings at baseline and follow-up in the PNI group (P = 0.007). Lower analgesic usage of patient controlled analgesia morphine (P < 0.0001), epipleural bupivacaine (P = 0.001), and oramorph/zomorph (P = 0.0002) were recorded. Our findings indicate that the use of phrenic nerve infiltration significantly reduced patient pain scores during the early postoperative period, particularly during movement. We believe that each technique has advantages and disadvantages; however, further studies with large sample size are warranted.

Pumps or Multiple Daily Injections in Pregnancy Involving Type 1 Diabetes: A Prespecified Analysis of the CONCEPTT Randomized Trial

OBJECTIVE

To compare glycemic control, quality of life, and pregnancy outcomes of women using insulin pumps and multiple daily injection therapy (MDI) during the Continuous Glucose Monitoring in Women With Type 1 Diabetes in Pregnancy Trial (CONCEPTT).

RESEARCH DESIGN AND METHODS

This was a prespecified analysis of CONCEPTT involving 248 pregnant women from 31 centers. Randomization was stratified for pump versus MDI and HbA_1c. The primary outcome was change in HbA_1c from randomization to 34 weeks' gestation. Key secondary outcomes were continuous glucose monitoring (CGM) measures, maternal-infant health, and patient-reported outcomes.

RESULTS

At baseline, pump users were more often in stable relationships (P = 0.003), more likely to take preconception vitamins (P = 0.03), and less likely to smoke (P = 0.02). Pump and MDI users had comparable first-trimester glycemia: HbA_1c 6.84 ± 0.71 vs. 6.95 ± 0.58% (51 ± 7.8 vs. 52 ± 6.3 mmol/mol) (P = 0.31) and CGM time in target (51 ± 14 vs. 50 ± 13%) (P = 0.40). At 34 weeks, MDI users had a greater decrease in HbA_1c (-0.55 ± 0.59 vs. -0.32 ± 0.65%, P = 0.001). At 24 and 34 weeks, MDI users were more likely to achieve target HbA_1c (P = 0.009 and P = 0.001, respectively). Pump users had more hypertensive disorders (P = 0.011), mainly driven by increased gestational hypertension (14.4 vs. 5.2%; P = 0.025), and more neonatal hypoglycemia (31.8 vs. 19.1%, P = 0.05) and neonatal intensive care unit (NICU) admissions >24 h (44.5 vs. 29.6%; P = 0.02). Pump users had a larger reduction in hypoglycemia-related anxiety (P = 0.05) but greater decline in health/well-being (P = 0.02).

CONCLUSIONS

In CONCEPTT, MDI users were more likely to have better glycemic outcomes and less likely to have gestational hypertension, neonatal hypoglycemia, and NICU admissions than pump users. These data suggest that implementation of insulin pump therapy is potentially suboptimal during pregnancy.