Sex and country differences in gout: cross-country comparison between Sweden and the UK

OBJECTIVE

Compare characteristics, sex differences, and management of gout in Sweden and the UK.

METHOD

The results from two separate primary care gout surveys from Sweden and the UK were compared. Participants aged ≥18 years with gout were sent a questionnaire asking about lifestyle, gout characteristics, uratelowering therapy (ULT), comorbidities, disability, and disease impact. For sex comparison, participants were pooled across countries.

RESULTS

In total, 784 (80% male) participants from Sweden and 500 (87% male) from the UK were included. Swedish patients were significantly older at gout onset, mean (SD) age 72 (12) versus 63 (13) years, (p<0.0001), with more comorbidities, and more frequent use of ULT (48% vs 35%, p=0.0005, age-adjusted). Use of alcohol and diuretics was significantly more common among UK patients, who also reported a higher number of gout flares, mean (SD) 2.2 (1.7) versus 1.6 (3.6), (p=0.003) age-adjusted. Females with gout were older at gout onset, mean (SD) age 67 (13) versus 56 (15), (p<0.0001), more often obese, and reported higher use of diuretics. Furthermore, females reported greater impact of gout, more pain and physical limitations, whereas no sex differences were seen in ULT or flares.

CONCLUSIONS

In the UK, gout was more frequently associated with modifiable risk factors. People with gout in Sweden were more commonly taking ULT and had lower frequency of gout flares and impact of gout. Females with gout more commonly took diuretics, had higher body mass index, and reported greater physical disability, which should be considered when managing gout in women.

Multiorgan MRI findings after hospitalisation with COVID-19 in the UK (C-MORE): a prospective, multicentre, observational cohort study

INTRODUCTION

The multiorgan impact of moderate to severe coronavirus infections in the post-acute phase is still poorly understood. We aimed to evaluate the excess burden of multiorgan abnormalities after hospitalisation with COVID-19, evaluate their determinants, and explore associations with patient-related outcome measures.

METHODS

In a prospective, UK-wide, multicentre MRI follow-up study (C-MORE), adults (aged ≥18 years) discharged from hospital following COVID-19 who were included in Tier 2 of the Post-hospitalisation COVID-19 study (PHOSP-COVID) and contemporary controls with no evidence of previous COVID-19 (SARS-CoV-2 nucleocapsid antibody negative) underwent multiorgan MRI (lungs, heart, brain, liver, and kidneys) with quantitative and qualitative assessment of images and clinical adjudication when relevant. Individuals with end-stage renal failure or contraindications to MRI were excluded. Participants also underwent detailed recording of symptoms, and physiological and biochemical tests. The primary outcome was the excess burden of multiorgan abnormalities (two or more organs) relative to controls, with further adjustments for potential confounders. The C-MORE study is ongoing and is registered with ClinicalTrials.gov, NCT04510025.

FINDINGS

Of 2710 participants in Tier 2 of PHOSP-COVID, 531 were recruited across 13 UK-wide C-MORE sites. After exclusions, 259 C-MORE patients (mean age 57 years [SD 12]; 158 [61%] male and 101 [39%] female) who were discharged from hospital with PCR-confirmed or clinically diagnosed COVID-19 between March 1, 2020, and Nov 1, 2021, and 52 non-COVID-19 controls from the community (mean age 49 years [SD 14]; 30 [58%] male and 22 [42%] female) were included in the analysis. Patients were assessed at a median of 5·0 months (IQR 4·2-6·3) after hospital discharge. Compared with non-COVID-19 controls, patients were older, living with more obesity, and had more comorbidities. Multiorgan abnormalities on MRI were more frequent in patients than in controls (157 [61%] of 259 vs 14 [27%] of 52; p<0·0001) and independently associated with COVID-19 status (odds ratio [OR] 2·9 [95% CI 1·5-5·8]; padjusted=0·0023) after adjusting for relevant confounders. Compared with controls, patients were more likely to have MRI evidence of lung abnormalities (p=0·0001; parenchymal abnormalities), brain abnormalities (p<0·0001; more white matter hyperintensities and regional brain volume reduction), and kidney abnormalities (p=0·014; lower medullary T1 and loss of corticomedullary differentiation), whereas cardiac and liver MRI abnormalities were similar between patients and controls. Patients with multiorgan abnormalities were older (difference in mean age 7 years [95% CI 4-10]; mean age of 59·8 years [SD 11·7] with multiorgan abnormalities vs mean age of 52·8 years [11·9] without multiorgan abnormalities; p<0·0001), more likely to have three or more comorbidities (OR 2·47 [1·32-4·82]; padjusted=0·0059), and more likely to have a more severe acute infection (acute CRP >5mg/L, OR 3·55 [1·23-11·88]; padjusted=0·025) than those without multiorgan abnormalities. Presence of lung MRI abnormalities was associated with a two-fold higher risk of chest tightness, and multiorgan MRI abnormalities were associated with severe and very severe persistent physical and mental health impairment (PHOSP-COVID symptom clusters) after hospitalisation.

INTERPRETATION

After hospitalisation for COVID-19, people are at risk of multiorgan abnormalities in the medium term. Our findings emphasise the need for proactive multidisciplinary care pathways, with the potential for imaging to guide surveillance frequency and therapeutic stratification.

FUNDING

UK Research and Innovation and National Institute for Health Research.

Engaging Ambulatory Cancer Patients to Develop and Validate a Comprehensive New Patient-Reported Outcomes Measure

PURPOSE/OBJECTIVE(S)

The ambulatory cancer program in Alberta, Canada routinely collects Patient-Reported Outcomes (PROs) using a common symptom rating measure, the Edmonton Symptom Assessment System-Revised (ESAS-r). The purpose of this study was to redesign, test, and validate a modified ESAS-r (the ESAS-r Cancer) for use in the province's new clinical information system and online patient portal.

MATERIALS/METHODS

Patient advisors participated in regular meetings to redesign the measure, creating expanded definitions for the original symptoms and new symptoms, added based on trends identified in our historical PRO data. To test the modified measure, patient advisors first completed the measure online to test the feasibility of remote electronic completion. Next, the advisors participated in cognitive interviews to discuss and finalize the wording of each symptom definition for clarity. To test the validity and reliability of the finalized measure, 1600 randomly sampled patients were mailed paper copies of the ESAS-r Cancer, ESAS-r, and a validated PRO measure called the Memorial System Assessment Scale-Short Form (MSAS-SF), which is often used with cancer patients. Canonical Correlation Analysis and exploratory factor analyses were performed to assess concurrent and construct validity of the ESAS-r Cancer against ESAS-r, using MSAS-SF as the gold standard. Cronbach's α was calculated to assess reliability.

RESULTS

The nine original ESAS-r symptoms were retained and six new symptoms were added to create the ESAS-r Cancer. All but one of the 26 patient advisors (96.2%) who completed the online measure did so without assistance. After two rounds of cognitive interviews all symptom definitions were finalized and deemed clear by almost all advisors. 461 patients (29% response rate) completed all three questionnaires. Using MSAS-SF as the gold standard, ESAS-r Cancer showed stronger canonical correlation than ESAS-r, indicating higher concurrent validity and fitting degree. ESAS-r Cancer also accounted for more information included on MSAS-SF than did ESAS-r, explaining more variance (75.2% vs. 73.5%). As revealed by factor analysis, the three-dimensional factor structure of ESAS-r Cancer outperformed the two-dimensional factor structure of ESAS-r, by allowing for new constructs within measurement. The reliability of ESAS-r Cancer was verified (Cronbach's α = .903, > threshold of 0.8) and slightly higher than ESAS-r (Cronbach's α = .884).

CONCLUSION

ESAS-r Cancer is now in use with patients throughout Alberta's cancer program. The redesign, testing, and validation process involved patient engagement throughout. Patient testing and perspectives were critical as ESAS-r Cancer is intended for use with ambulatory cancer patients. ESAS-r Cancer can help ensure patients are included in care decisions and that their perspectives are involved in guiding care.

Handling prevents and reverses cognitive deficits induced by sub-chronic phencyclidine in a model for schizophrenia in rats

Treatments for schizophrenia are not effective in ameliorating cognitive deficits. Therefore, novel therapies are needed to treat cognitive impairments associated with schizophrenia (CIAS), which are modelled in rats through administration of sub-chronic phencyclidine (scPCP). We have previously shown that enrichment via voluntary exercise prevents and reverses impairments in novel object recognition (NOR) in this model. The present study aimed to investigate if handling could prevent delay-induced NOR deficits and prevent and reverse scPCP-induced NOR deficits. Two cohorts of adult female Lister Hooded rats were used. In experiment one, handling (five minutes/day, five days/week for two weeks), took place before scPCP administration (2 mg/kg, i.p. twice-daily for seven days). NOR tests were conducted at two, four, and seven weeks post-handling with a one-minute inter-trial interval (ITI) and at five weeks post-dosing with a six-hour ITI. In experiment two, rats were handled after scPCP administration and tested immediately in the one-minute ITI NOR task and again at two weeks post-handling. In both handling regimens, the scPCP control groups failed to discriminate novelty, conversely the scPCP handled groups significantly discriminated in this task. In the 6 h ITI test, vehicle control and scPCP control failed to discriminate novelty; however, the vehicle handled and scPCP handled groups did significantly discriminate. Handling rats prevented and reversed scPCP-induced deficits and prevented delay-induced NOR deficits. These findings add to evidence that environmental enrichment is a viable treatment for cognitive deficits in rodent tests and models of relevance to schizophrenia, with potential to translate into effective treatments for CIAS.

The influence of anastomotic techniques on postoperative anastomotic complications: Results of the Oesophago-Gastric Anastomosis Audit

BACKGROUND

The optimal anastomotic techniques in esophagectomy to minimize rates of anastomotic leakage and conduit necrosis are not known. The aim of this study was to assess whether the anastomotic technique was associated with anastomotic failure after esophagectomy in the international Oesophago-Gastric Anastomosis Audit cohort.

METHODS

This prospective observational multicenter cohort study included patients undergoing esophagectomy for esophageal cancer over 9 months during 2018. The primary exposure was the anastomotic technique, classified as handsewn, linear stapled, or circular stapled. The primary outcome was anastomotic failure, namely a composite of anastomotic leakage and conduit necrosis, as defined by the Esophageal Complications Consensus Group. Multivariable logistic regression modeling was used to identify the association between anastomotic techniques and anastomotic failure, after adjustment for confounders.

RESULTS

Of the 2238 esophagectomies, the anastomosis was handsewn in 27.1%, linear stapled in 21.0%, and circular stapled in 51.9%. Anastomotic techniques differed significantly by the anastomosis sites (P < .001), with the majority of neck anastomoses being handsewn (69.9%), whereas most chest anastomoses were stapled (66.3% circular stapled and 19.3% linear stapled). Rates of anastomotic failure differed significantly among the anastomotic techniques (P < .001), from 19.3% in handsewn anastomoses, to 14.0% in linear stapled anastomoses, and 12.1% in circular stapled anastomoses. This effect remained significant after adjustment for confounding factors on multivariable analysis, with an odds ratio of 0.63 (95% CI, 0.46-0.86; P = .004) for circular stapled versus handsewn anastomosis. However, subgroup analysis by anastomosis site suggested that this effect was predominantly present in neck anastomoses, with anastomotic failure rates of 23.2% versus 14.6% versus 5.9% for handsewn versus linear stapled anastomoses versus circular stapled neck anastomoses, compared with 13.7% versus 13.8% versus 12.2% for chest anastomoses.

CONCLUSIONS

Handsewn anastomoses appear to be independently associated with higher rates of anastomotic failure compared with stapled anastomoses. However, this effect seems to be largely confined to neck anastomoses, with minimal differences between techniques observed for chest anastomoses. Further research into standardization of anastomotic approach and techniques may further improve outcomes.

Clinical characteristics with inflammation profiling of long COVID and association with 1-year recovery following hospitalisation in the UK: a prospective observational study

BACKGROUND

No effective pharmacological or non-pharmacological interventions exist for patients with long COVID. We aimed to describe recovery 1 year after hospital discharge for COVID-19, identify factors associated with patient-perceived recovery, and identify potential therapeutic targets by describing the underlying inflammatory profiles of the previously described recovery clusters at 5 months after hospital discharge.

METHODS

The Post-hospitalisation COVID-19 study (PHOSP-COVID) is a prospective, longitudinal cohort study recruiting adults (aged ≥18 years) discharged from hospital with COVID-19 across the UK. Recovery was assessed using patient-reported outcome measures, physical performance, and organ function at 5 months and 1 year after hospital discharge, and stratified by both patient-perceived recovery and recovery cluster. Hierarchical logistic regression modelling was performed for patient-perceived recovery at 1 year. Cluster analysis was done using the clustering large applications k-medoids approach using clinical outcomes at 5 months. Inflammatory protein profiling was analysed from plasma at the 5-month visit. This study is registered on the ISRCTN Registry, ISRCTN10980107, and recruitment is ongoing.

FINDINGS

2320 participants discharged from hospital between March 7, 2020, and April 18, 2021, were assessed at 5 months after discharge and 807 (32·7%) participants completed both the 5-month and 1-year visits. 279 (35·6%) of these 807 patients were women and 505 (64·4%) were men, with a mean age of 58·7 (SD 12·5) years, and 224 (27·8%) had received invasive mechanical ventilation (WHO class 7-9). The proportion of patients reporting full recovery was unchanged between 5 months (501 [25·5%] of 1965) and 1 year (232 [28·9%] of 804). Factors associated with being less likely to report full recovery at 1 year were female sex (odds ratio 0·68 [95% CI 0·46-0·99]), obesity (0·50 [0·34-0·74]) and invasive mechanical ventilation (0·42 [0·23-0·76]). Cluster analysis (n=1636) corroborated the previously reported four clusters: very severe, severe, moderate with cognitive impairment, and mild, relating to the severity of physical health, mental health, and cognitive impairment at 5 months. We found increased inflammatory mediators of tissue damage and repair in both the very severe and the moderate with cognitive impairment clusters compared with the mild cluster, including IL-6 concentration, which was increased in both comparisons (n=626 participants). We found a substantial deficit in median EQ-5D-5L utility index from before COVID-19 (retrospective assessment; 0·88 [IQR 0·74-1·00]), at 5 months (0·74 [0·64-0·88]) to 1 year (0·75 [0·62-0·88]), with minimal improvements across all outcome measures at 1 year after discharge in the whole cohort and within each of the four clusters.

INTERPRETATION

The sequelae of a hospital admission with COVID-19 were substantial 1 year after discharge across a range of health domains, with the minority in our cohort feeling fully recovered. Patient-perceived health-related quality of life was reduced at 1 year compared with before hospital admission. Systematic inflammation and obesity are potential treatable traits that warrant further investigation in clinical trials.

FUNDING

UK Research and Innovation and National Institute for Health Research.

P-265 A low-lactate undisturbed culture medium protocol provides an increase in usable blastocysts on day 5 vs. day 6

Study question

Does a culture medium with more physiological concentrations of lactate provide more usable blastocysts on day 5 vs day 6 compared to higher lactate medium.

Summary answer

1mm lactate medium supports a noticeable trend for more usable blastocysts on day 5 compared to day 6.

What is known already

Previous studies have shown that blastocyst utilization and normal embryo ploidy are more significant when a low lactate (1mM) culture medium is utilized in the laboratory compared to higher lactate (5-10mM) concentrations. It is presumed that a lactate gradient (from high to low) provides a more optimal embryo growth environment; However, it can be debated that lower lactate concentrations are more physiological and less disruptive to embryo metabolism, particularly at the blastocyst stage.

Study design, size, duration

From January through March 2020, a split sibling oocyte study was performed on 50 patient cycles, each with a minimum of 9 oocytes retrieved. Oocytes were divided between low-lactate Continuous Single Culture Medium-NX and the laboratory’s current culture system of higher lactate Continuous Single Culture Medium following aspiration, thus resulting in 276 oocytes and 257 oocytes, respectively. The resulting zygotes were subsequently cultured from fertilization events to the blastocyst stage in their corresponding medium.

Participants/materials, setting, methods

The study was undertaken in a private IVF laboratory. No consideration was given to the patient age, stimulation protocol, or diagnosis indication. Comparative parameters for analysis included fertilization success and usable blastocysts through day 6 culture. Usable blastocysts were defined as any blastocyst transferred in a fresh cycle, or vitrified for future use. The denominator for such determination was the total normal 2PNs at fertilization check.

Main results and the role of chance

Our data demonstrates the potential advantages of culturing embryos in an undisturbed culture medium with a 1mM lactate concentration as opposed to a more traditional, higher lactate concentration. The overall blastocyst utilization rate (BUR) on day 5 was 27% in low lactate vs. 20% in high lactate and 12% vs 15% for day 6, thus resulting in more usable blastocysts on day 5, as well as overall, in low lactate culture. When stratified by patient age, embryos cultured in low lactate showed an increase in BUR on day 5 across all age groups. In patients 35-37 years old, a 13% increase in usable blastocysts on day 5 was observed, followed by patients 41-42 which had a 12% BUR increase in low lactate versus higher lactate. 38-40 year olds had a 7% increase in low lactate and &lt;35 increased by 3% on day 5. Interestingly, our data also shows a significant increase in normal fertilization outcomes, both by ICSI and overall with conventional insemination, in low lactate vs higher lactate (79% vs 71% respectively at p &lt; 0.05).

Limitations, reasons for caution

Need for increased n to determine significance along with further studies to understand the metabolic pathways which lead to earlier blastocyst development on day 5 vs. day 6. Additionally, there needs to be more investigative studies into the role a lower lactate concentration plays in normal fertilization outcome improvement.

Wider implications of the findings

A low lactate culture medium supports an increase in the availability of usable blastocysts on day 5. This finding can improve laboratory workflow efficiency through patient scheduling for fresh day 5 embryo transfers as well as allocate resources to accommodate more embryo vitrification on the 5th day of embryo culture.

Trial registration number

NA

P-225 Positive effects of low-lactate culture medium on embryo development and blastocyst ploidy status: a 3.5-year multi-clinic retrospective review

Study question

Can lower concentrations of lactate in culture medium have a positive effect on day 5 and day 6 blastocyst ploidy determined by PGT-A?

Summary answer

Embryos cultured to the blastocyst stage in medium containing 1mM concentration of lactate vs. 6mM or 10mM are significantly more likely to be euploid.

What is known already

Extended culture to the blastocyst stage is required for PGT-A analysis following trophectoderm biopsy. Although there are many published studies which debate the use of a single-step culture media vs. sequential culture media, very few studies address the importance of culture conditions and media component concentrations as it relates to ploidy of the resulting embryo. Previous media validation studies do support the benefits of lower lactate levels in culture media with an increase in the total number of usable blastocysts, particularly in older patients.

Study design, size, duration

A multi-lab retrospective review with the first lab using high lactate (6mM) continuous culture system (January 2016 through December 2017) compared to a low lactate continuous culture system, January 2018 through July 2021, (&gt;13,000 embryos). In another lab, a retrospective review was undertaken to compare their sequential culture system in a high lactate concentration (10mM) (January 2016 through October 2017) with a low lactate continuous culture system from October 2017 through July 2021 (&gt;12,000 embryos).

Participants/materials, setting, methods

The entire patient population in the timeframes reviewed were included with no allowances given to demographics in two separate private IVF clinics in different regions of the country. Analysis included the ploidy status of the embryos as well as the usable blastocyst rate. Ploidy status was determined by trophectoderm biopsy/PGT-A analysis on Day 5 and 6. Usable blastocysts were determined by any blastocyst that was of a quality to be transferred or vitrified.

Main results and the role of chance

Our data indicates that the lower level of lactate concentration in Continuous Single Culture Medium-NX (1mM) supports a significant increase in euploidy in day 5 and day 6 blastocysts compared to higher lactate concentrations, both 6mM (Continuous Single Culture Medium) and 10mM (Sequential G1/G2). The euploid rate of day 5 blastocysts cultured in 1mM vs. 6mM lactate was 58.4% compared to 52.1% (p &lt; 0.001) and 51.0% vs. 41.4% (p &lt; 0.001) for day 6 blastocysts. The percentage of day 5 euploid blastocysts in 1mM vs. 10mM was 54.3% vs. 50.0% (p &lt; 0.05) and 41.3% vs. 39.4% (not significant) respectively for day 6 blastocysts. The euploidy rate in 1mM vs 10mM lactate concentration, as a function of the blastocyst utilization rate, results in a 3.3% increase in total normal blastocysts (p &lt; 0.001) on day 5 and a 1.4% increase of the same on day 6 (p &lt; 0.05). Interestingly, when the total number of chromosomally normal blastocysts is similarly compared in 1mM vs 6mM, there is only a 0.8% increase in the 6mM group vs the 1mM group (p &lt; 0.05); However, on day 6, 1mM results in an increase of 1.3% over 6mM (p &lt; 0.01).

Limitations, reasons for caution

As patient age is the strongest predictor for blastocyst development and embryonic aneuploidy, additional analysis is being conducted to stratify the data by maternal age in order to identify if low-lactate culture media provides a more suitable metabolic environment for specific age groups.

Wider implications of the findings

Although the specific mechanism involved in the alteration of the cytogenetic composition of embryos cultured in higher lactate medium are unknown at this time, these findings support the importance and need to further investigate the epigenetic effects of culture media components and concentrations on the developing embryo.

Trial registration number

not applicable

P-267 A continuous culture medium with a lower concentration of lactate has a pronounced effect on the percentage of usable blastocysts on day 5

Study question

Does Continuous Single Culture Medium NX, an embryo culture medium containing 1mM lactate, support increased blastocyst development over high lactate Vitrolife G1/G2 Series sequential culture?

Summary answer

There is a statistically significant increase in day 5 usable blastocysts in low lactate culture medium compared to the one with high lactate medium.

What is known already

Studies have shown that day 5 is the most desirable day to obtain blastocysts that are of an expansion, grade and quality to be utilized for transfer and/or vitrification procedures as those result in the highest success of clinical pregnancy,as compared to day 6/ 7 blastocysts, that do not meet criteria. Moreover, recent studies have indicated that there is an increase in chromosomal correctness of embryos cultured in a 1mM lactate environment as opposed to the higher 6-10mM lactate concentrations that have historically been believed necessary for successful blastocyst culture and resulting pregnancy.

Study design, size, duration

A prospective split sibling oocytes study was performed on 50 ICSI and IMSI cycles from October 2020 through April 2021. Oocytes were divided into the low lactate medium and high lactate gradient medium immediately following ICSI/IMSI and thereafter cultured in those medium until the final day of blastocyst culture. All patient ages were included in the sample population.

Participants/materials, setting, methods

This study was carried out in a private clinic. All patient stimulation protocol information and diagnosis’ were recorded; however, there was no restriction on participation. The endpoint was to analyse the resulting usable blastocyst rates on day 5 and day 6 in both arms of the study, using a denominator of normal 2PN fertilization. If a blastocyst was transferred or cryopreserved on day 5 or day 6, it was determined to be usable.

Main results and the role of chance

The resulting data was stratified not only by day 5 and day 6 usable blastocyst rates but also by patient age. It illustrates a statistically significant improvement in day 5 usable blastocysts for patients &lt;35 in CSCM-NXC vs G1/G2 at 56% and 42%, respectively, a 14% increase (p &lt; .05). The overall day 5 usable blastocyst rate was also statistically significant in CSCM-NXC (47%) as compared to G1/G2 (36%), (p &lt; .05) with all ages considered. Additionally, on day 5, there was a higher percentage of usable blastocysts demonstrated in low lactate vs high in patients aged 35-37 (65% vs 42%, respectively) and 41-42 (41% vs 15%). Statistical significance was reversed in patients &lt;35 on day 6, with G1/G2 having 24% usable blasts and CSCM-NXC 10% (p &lt; .05). Interestingly, though not significant, G1/G2 had an increase in usable blastocyst percentage on day 5 in patients &gt;42 (20% vs 11%), but overall, CSCM-NXC saw an increase in that same age group by 16%.

Limitations, reasons for caution

Though statistical significance was found in this study, a greater number will help to bolster the statistical power of the observations. Additionally, more studies are needed in order to ascertain if low lactate has an effect on the development prior to ICSI and resulting culture.

Wider implications of the findings

The mechanism of action that leads to the successful embryo development in low lactate embryo culture medium is vastly unknown, so further studies are required in order to understand the complexities and the impact of the observations provided.

Trial registration number

not applicable.

Textbook outcome following oesophagectomy for cancer: international cohort study

Background

Textbook outcome has been proposed as a tool for the assessment of oncological surgical care. However, an international assessment in patients undergoing oesophagectomy for oesophageal cancer has not been reported. This study aimed to assess textbook outcome in an international setting.

Methods

Patients undergoing curative resection for oesophageal cancer were identified from the international Oesophagogastric Anastomosis Audit (OGAA) from April 2018 to December 2018. Textbook outcome was defined as the percentage of patients who underwent a complete tumour resection with at least 15 lymph nodes in the resected specimen and an uneventful postoperative course, without hospital readmission. A multivariable binary logistic regression model was used to identify factors independently associated with textbook outcome, and results are presented as odds ratio (OR) and 95 per cent confidence intervals (95 per cent c.i.).

Results

Of 2159 patients with oesophageal cancer, 39.7 per cent achieved a textbook outcome. The outcome parameter ‘no major postoperative complication’ had the greatest negative impact on a textbook outcome for patients with oesophageal cancer, compared to other textbook outcome parameters. Multivariable analysis identified male gender and increasing Charlson comorbidity index with a significantly lower likelihood of textbook outcome. Presence of 24-hour on-call rota for oesophageal surgeons (OR 2.05, 95 per cent c.i. 1.30 to 3.22; P = 0.002) and radiology (OR 1.54, 95 per cent c.i. 1.05 to 2.24; P = 0.027), total minimally invasive oesophagectomies (OR 1.63, 95 per cent c.i. 1.27 to 2.08; P &lt; 0.001), and chest anastomosis above azygous (OR 2.17, 95 per cent c.i. 1.58 to 2.98; P &lt; 0.001) were independently associated with a significantly increased likelihood of textbook outcome.

Conclusion

Textbook outcome is achieved in less than 40 per cent of patients having oesophagectomy for cancer. Improvements in centralization, hospital resources, access to minimal access surgery, and adoption of newer techniques for improving lymph node yield could improve textbook outcome.

Textbook outcome following oesophagectomy for cancer: international cohort study

BACKGROUND

Textbook outcome has been proposed as a tool for the assessment of oncological surgical care. However, an international assessment in patients undergoing oesophagectomy for oesophageal cancer has not been reported. This study aimed to assess textbook outcome in an international setting.

METHODS

Patients undergoing curative resection for oesophageal cancer were identified from the international Oesophagogastric Anastomosis Audit (OGAA) from April 2018 to December 2018. Textbook outcome was defined as the percentage of patients who underwent a complete tumour resection with at least 15 lymph nodes in the resected specimen and an uneventful postoperative course, without hospital readmission. A multivariable binary logistic regression model was used to identify factors independently associated with textbook outcome, and results are presented as odds ratio (OR) and 95 per cent confidence intervals (95 per cent c.i.).

RESULTS

Of 2159 patients with oesophageal cancer, 39.7 per cent achieved a textbook outcome. The outcome parameter 'no major postoperative complication' had the greatest negative impact on a textbook outcome for patients with oesophageal cancer, compared to other textbook outcome parameters. Multivariable analysis identified male gender and increasing Charlson comorbidity index with a significantly lower likelihood of textbook outcome. Presence of 24-hour on-call rota for oesophageal surgeons (OR 2.05, 95 per cent c.i. 1.30 to 3.22; P = 0.002) and radiology (OR 1.54, 95 per cent c.i. 1.05 to 2.24; P = 0.027), total minimally invasive oesophagectomies (OR 1.63, 95 per cent c.i. 1.27 to 2.08; P < 0.001), and chest anastomosis above azygous (OR 2.17, 95 per cent c.i. 1.58 to 2.98; P < 0.001) were independently associated with a significantly increased likelihood of textbook outcome.

CONCLUSION

Textbook outcome is achieved in less than 40 per cent of patients having oesophagectomy for cancer. Improvements in centralization, hospital resources, access to minimal access surgery, and adoption of newer techniques for improving lymph node yield could improve textbook outcome.

Postoperative outcomes in oesophagectomy with trainee involvement

BACKGROUND

The complexity of oesophageal surgery and the significant risk of morbidity necessitates that oesophagectomy is predominantly performed by a consultant surgeon, or a senior trainee under their supervision. The aim of this study was to determine the impact of trainee involvement in oesophagectomy on postoperative outcomes in an international multicentre setting.

METHODS

Data from the multicentre Oesophago-Gastric Anastomosis Study Group (OGAA) cohort study were analysed, which comprised prospectively collected data from patients undergoing oesophagectomy for oesophageal cancer between April 2018 and December 2018. Procedures were grouped by the level of trainee involvement, and univariable and multivariable analyses were performed to compare patient outcomes across groups.

RESULTS

Of 2232 oesophagectomies from 137 centres in 41 countries, trainees were involved in 29.1 per cent of them (n = 650), performing only the abdominal phase in 230, only the chest and/or neck phases in 130, and all phases in 315 procedures. For procedures with a chest anastomosis, those with trainee involvement had similar 90-day mortality, complication and reoperation rates to consultant-performed oesophagectomies (P = 0.451, P = 0.318, and P = 0.382, respectively), while anastomotic leak rates were significantly lower in the trainee groups (P = 0.030). Procedures with a neck anastomosis had equivalent complication, anastomotic leak, and reoperation rates (P = 0.150, P = 0.430, and P = 0.632, respectively) in trainee-involved versus consultant-performed oesophagectomies, with significantly lower 90-day mortality in the trainee groups (P = 0.005).

CONCLUSION

Trainee involvement was not found to be associated with significantly inferior postoperative outcomes for selected patients undergoing oesophagectomy. The results support continued supervised trainee involvement in oesophageal cancer surgery.

Experiences of Student Circus Arts Performers Undertaking a Shoulder Rehabilitation Program Via Telehealth Consultation During the COVID-19 Pandemic

OBJECTIVE

To explore the subjective experiences of student circus arts performers with atraumatic shoulder instability undertaking a 12-week shoulder rehabilitation program during the COVID-19 pandemic lockdown, in Melbourne, Australia.

METHODS

Using a qualitative design, 14 circus arts students from the National Institute of Circus Arts (Australia) were individually interviewed via teleconsultation. All interviews were recorded, transcribed, and analysed using inductive thematic analysis.

RESULTS

Five overarching themes were identified: (i) impact (physical and mental), (ii) opportunity, (iii) developing routine, (iv) client-therapist relationship, and (v) transformation. All participants reported positive physical changes to their shoulder including increases in strength, stability, range of motion, less pain, "clicking" and "clunking," improved posture, muscle memory, as well as carry-over to functional circus activities. The pandemic's mental impact varied across the cohort, with positive and negative experiences described in relation to cognitive, social, and affective factors. Most performers felt the pandemic provided an opportunity to focus on rehabilitation of their shoulder. The program effects were also underpinned by positive client-therapist relationships and a progressive transformation of learning where students gained knowledge of their condition, developed tools to manage their current shoulder impairment, and learned how to apply this new knowledge to future management of their condition.

CONCLUSION

A shoulder exercise intervention delivered via teleconsultation during the COVID-19 pandemic resulted in subjective reports of positive physical changes to the participants' shoulder health complaint. This was facilitated through client-physiotherapist relationships, providing structure during uncertain times, and by providing education to help in understanding their condition and its future management.

P–213 Comparative optical analysis of spindle reformation after oocyte vitrification with media containing differing basal formulations

Study question

Do the base ingredients and total composition of vitrification media have an effect on meiotic spindle reformation in warmed donor oocytes?

Summary answer

Meiotic spindle reformation occurs more readily in donor oocytes vitrified and warmed with a contemporary culture media based vitrification formulation than in traditional vitrification media.

What is known already

Embryo culture trends continue towards more freeze-all cycles and oocyte preservation is becoming more prevalent across all age groups, thus vitrification continues to serve a pivotal role in today’s laboratory; however, the formulation of vitrification media remains largely unchanged from the m199 or mHTF base composition of antiquated slow freeze media. Literature identifies temperature as a key determiner in spindle reformation. Our preliminary data utilizing a robust vitrification medium with a basal formulation specifically designed for human embryo growth demonstrates a pronounced positive effect on oocytes post-warm in regard to spindle recovery time.

Study design, size, duration

In a prospective study, 30 oocytes obtained from a diverse population of 10 oocyte donors donating to an egg bank were imaged prior to vitrification to identify the meiotic spindle using the Oosight Imaging System (Hamilton Thorne). Donor oocytes were then split between two vitrification media groups, Vitrification Kit NX (FujiFilm Irvine Scientific) and Vitrification Media (Kitazato USA). After warming, oocytes were again imaged at various time points and meiotic spindle retardance was noted.

Participants/materials, setting, methods

Oocytes from approved egg bank donors were imaged, vitrified and warmed using protocols recommended by the manufacturers. The oocyte donors were all cycled and retrieved in the same private IVF Clinic and Laboratory between October 2019 and February 2020. Temperature of media, culture dishes, incubators and work stations were all monitored and maintained. Retrieved oocytes were imaged prior to vitrification. Oocytes were imaged immediately upon warm, and at 1 and 3 hours post warm.

Main results and the role of chance

Oocyte survival was similar across the two media groups, with Vitrification Kit NX at 86.7% and Vitrification Media at 80.0% survival. 100% of the degenerated oocytes in Vitrification Kit NX did not display an initial meiotic spindle when imaged prior to vitrification as opposed to 67% of the degenerate oocytes in Vitrification Media. Upon warming, immediate imaging showed oocytes from Vitrification Kit NX displayed a spindle at a rate of 41.7%, while Vitrification Media allowed this in 0% of the oocytes. At 1-hour post warm, Vitrification Kit NX and Vitrification Media displayed meiotic spindles in 83.3% and 22.2% of oocytes, respectively. The final time point was imaged at 3-hours post warm and showed meiotic spindle reformation in 91.7% of Vitrification Kit NX oocytes and 66.7% of Vitrification Media oocytes. While none of the time points imaged show significance, there is a defined trend towards a faster rate of meiotic spindle recovery in vitrification media formulated with a more modern culture media base.

Limitations, reasons for caution

The preliminary findings of this study offer that the composition and formulation of the vitrification medium perhaps do have an effect on the reformation of the meiotic spindle post-warm; however, more information is needed and a larger population size must be examined prior to discerning any significance.

Wider implications of the findings: If, through further study and imaging, it is ascertained that meiotic spindle reformation is determined in part by the vitrification media composition, it could lead to potentially healthier warmed oocytes for the patient and less workload and scheduling stress on the embryologists due to shorter wait times prior to ICSI.

Trial registration number

Not applicable

Safety of hormone replacement therapy in women with a history of cervical adenocarcinoma

OBJECTIVES

Studies investigating the safety of hormone replacement therapy in cervical cancer have predominantly included patients with squamous disease. Pathological studies have identified estrogen receptor positivity in cervical adenocarcinomas. A recent small case-control study suggested a trend towards reduced survival with hormone replacement therapy in cervical adenocarcinomas. Our objective was to determine if hormone replacement therapy use in patients treated for cervical adenocarcinomas is detrimental to survival.

STUDY DESIGN

A retrospective review of all women under the age of 50 with stage 1B-2B cervical adenocarcinomas diagnosed between 1 November 2000 and 24 September 2019. Women were categorised into three groups: ovaries conserved (OVCON); or iatrogenic menopause with (IM-HRT) or without (IM-NOHRT) hormone replacement therapy. Hormone replacement therapy use was defined on an intention to treat basis. Statistical analysis was performed using Kaplan-Meier and Cox proportional hazards methods.

MAIN OUTCOME MEASURES

Overall (OS), disease specific (DSS) and progression free (PFS) survival.

RESULTS

A total of 58 women (mean age 38.5 ± 6.6) were included in the study of whom 25 (43.1%) had OVCON, 20 (34.4%) had IM-HRT and 13 (22.4%) had IM-NOHRT. No menopause-associated deaths occurred. Although five-year DSS was 73% in IM-NOHRT compared to 95% in IM-HRT and 95% in OVCON, these differences were not statistically significant. Five-year PFS was 68% in IM-NOHRT compared to 90% in IM-HRT and 81% in OVCON but again, these differences were not statistically significant.

CONCLUSION

In this small study, hormone replacement therapy does not appear to be detrimental to survival in cervical adenocarcinomas. There is a trend towards improved survival with hormone replacement therapy. Larger studies are required to substantiate these findings.

Mortality from esophagectomy for esophageal cancer across low, middle, and high-income countries: An international cohort study

BACKGROUND

No evidence currently exists characterising global outcomes following major cancer surgery, including esophageal cancer. Therefore, this study aimed to characterise impact of high income countries (HIC) versus low and middle income countries (LMIC) on the outcomes following esophagectomy for esophageal cancer.

METHOD

This international multi-center prospective study across 137 hospitals in 41 countries included patients who underwent an esophagectomy for esophageal cancer, with 90-day follow-up. The main explanatory variable was country income, defined according to the World Bank Data classification. The primary outcome was 90-day postoperative mortality, and secondary outcomes were composite leaks (anastomotic leak or conduit necrosis) and major complications (Clavien-Dindo Grade III - V). Multivariable generalized estimating equation models were used to produce adjusted odds ratios (ORs) and 95% confidence intervals (CI95%).

RESULTS

Between April 2018 to December 2018, 2247 patients were included. Patients from HIC were more significantly older, with higher ASA grade, and more advanced tumors. Patients from LMIC had almost three-fold increase in 90-day mortality, compared to HIC (9.4% vs 3.7%, p < 0.001). On adjusted analysis, LMIC were independently associated with higher 90-day mortality (OR: 2.31, CI95%: 1.17-4.55, p = 0.015). However, LMIC were not independently associated with higher rates of anastomotic leaks (OR: 1.06, CI95%: 0.57-1.99, p = 0.9) or major complications (OR: 0.85, CI95%: 0.54-1.32, p = 0.5), compared to HIC.

CONCLUSION

Resections in LMIC were independently associated with higher 90-day postoperative mortality, likely reflecting a failure to rescue of these patients following esophagectomy, despite similar composite anastomotic leaks and major complication rates to HIC. These findings warrant further research, to identify potential issues and solutions to improve global outcomes following esophagectomy for cancer.

Comparison of short-term outcomes from the International Oesophago-Gastric Anastomosis Audit (OGAA), the Esophagectomy Complications Consensus Group (ECCG), and the Dutch Upper Gastrointestinal Cancer Audit (DUCA)

BACKGROUND

The Esophagectomy Complications Consensus Group (ECCG) and the Dutch Upper Gastrointestinal Cancer Audit (DUCA) have set standards in reporting outcomes after oesophagectomy. Reporting outcomes from selected high-volume centres or centralized national cancer programmes may not, however, be reflective of the true global prevalence of complications. This study aimed to compare complication rates after oesophagectomy from these existing sources with those of an unselected international cohort from the Oesophago-Gastric Anastomosis Audit (OGAA).

METHODS

The OGAA was a prospective multicentre cohort study coordinated by the West Midlands Research Collaborative, and included patients undergoing oesophagectomy for oesophageal cancer between April and December 2018, with 90 days of follow-up.

RESULTS

The OGAA study included 2247 oesophagectomies across 137 hospitals in 41 countries. Comparisons with the ECCG and DUCA found differences in baseline demographics between the three cohorts, including age, ASA grade, and rates of chronic pulmonary disease. The OGAA had the lowest rates of neoadjuvant treatment (OGAA 75.1 per cent, ECCG 78.9 per cent, DUCA 93.5 per cent; P < 0.001). DUCA exhibited the highest rates of minimally invasive surgery (OGAA 57.2 per cent, ECCG 47.9 per cent, DUCA 85.8 per cent; P < 0.001). Overall complication rates were similar in the three cohorts (OGAA 63.6 per cent, ECCG 59.0 per cent, DUCA 62.2 per cent), with no statistically significant difference in Clavien-Dindo grades (P = 0.752). However, a significant difference in 30-day mortality was observed, with DUCA reporting the lowest rate (OGAA 3.2 per cent, ECCG 2.4 per cent, DUCA 1.7 per cent; P = 0.013).

CONCLUSION

Despite differences in rates of co-morbidities, oncological treatment strategies, and access to minimal-access surgery, overall complication rates were similar in the three cohorts.

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.

Getting more from standard rotator cuff strengthening exercises

BACKGROUND

A simple modification to standard rotator cuff exercises using an additional resistance band around the scapula has been recommended in the clinical setting, postulated to encourage activation of the posterior scapular stabilisers and increase rotator cuff activation. The aim of this clinical laboratory study was to compare scapular and rotator cuff muscle activation between standard and modified exercises.

METHODS

Electromyographic data were collected from 10 healthy adults via surface and intramuscular electrodes from the scapular and rotator cuff muscles. Internal and external rotation exercises of the shoulder with the arm abducted to 0°, 45° and 90° were performed using one handheld resistance band (standard) or two bands with the additional band applied to the scapula (modified).

RESULTS

Activation of the trapezii and rhomboid muscles during the modified exercises at 0° and 45° of abduction was significantly greater when compared to the standard exercises (P < 0.05). No significant differences were found in rotator cuff muscle activation.

DISCUSSION

Applying resistance to the posterior scapula increases activation of some scapular stabilising muscles particularly in lower ranges of abduction. This study provides preliminary evidence that this simple modification can elicit greater scapular muscle activity, potentially producing enhanced exercise outcomes with minimal additional effort.

Patient-reported outcomes in Alberta: rationale, scope, and design of a database initiative

Background

The collection of patient reported outcomes (pros) is a standard of care in many cancer organizations. In Alberta, pros have been integrated into routine clinical practice since 2012. This longitudinal collection of pros provides a wealth of data and a unique research opportunity to improve cancer care. The goal of this pro data initiative is to establish a robust repository of information for ongoing clinical care and research focused on pros. In this paper, we describe the rationale, scope, and design of this initiative.

Implementation

The initiative consists of pros and other administrative health data from the province of Alberta. Retrieval of health data from a variety of provincially governed sources will create a platform of information on pros, health outcomes, cancer data, other health conditions, and demographics. The aims of the initiative are to use the data to inform best practices at the point of care; to conduct health services research, particularly clinical epidemiology studies; and to evaluate a variety of pro-related outcomes.

Discussion

Because this effort represents our first to integrate routinely collected pros with other administrative health data, a unique and robust data repository will be created. The ability to integrate various types of data will provide a comprehensive mechanism to evaluate a variety of outcomes. Because cancer care in Alberta is governed by a single health care system, the data linkages will include population health and psychosocial cancer data. We anticipate that research related to this initiative will ultimately help to inform more patient-centred care.

Novel outreach settings to enhance sexually transmitted infection/HIV awareness, diagnosis and treatment in hard-to-reach populations

Despite recent rises in the number of cases of sexually transmitted infections (STIs) such as syphilis and gonorrhoea in England and increasing rates of HIV diagnosis among several men who have sex with men populations, many individuals are still not engaging with sexual health services. The John Hunter Clinic for Sexual Health, Chelsea and Westminster Hospital, London set up outreach clinics at the two world's largest adult lifestyle exhibitions in 2013 and 2015. This was the first time that a sexual health screening and promotion service was available at these large-scale (over 10,000 attendees at each) adult lifestyle events. A total of 381 individuals underwent STI screening across the two events. Nineteen (5.0%) patients were diagnosed with an infection. Twelve (3.1%) patients with Chlamydia trachomatis, three (0.8%) patients with syphilis, one (0.3%) patient with Neisseria gonorrhoeae, one (0.3%) patient with HIV, one (0.3%) patient with hepatitis B and one (0.3%) patient with hepatitis C. All 19 patients were promptly contacted with their results and had arrangements made for treatment or were referred for specialist follow up. Where possible, contact tracing was also performed. Implementing such outreach-based projects is challenged by lack of on-site laboratory support, high staffing demands and potentially high costs. However, we achieved a total HIV screening uptake rate of 94.5% amongst our outreach clinic attendees (versus 67% nationally in conventional sexual health clinic attendees) with an HIV positivity rate of 0.3% (versus 0.2% nationally in high HIV prevalence band populations). Additionally, 30.7% had never been tested for HIV previously (versus 20.7% nationally). Our work demonstrates that these strategies can help to address issues related to lack of STI/HIV screening in hard-to-reach populations and promote risk reduction behaviour.

Effect of expiratory positive airway pressure on tidal volume during non-invasive ventilation

During non-invasive ventilation (NIV), tidal volume ( V_t) will depend upon the difference between inspiratory and expiratory positive airway pressure (IPAP and EPAP, respectively), provided the respiratory muscles are relaxed and the lungs and chest wall therefore move along their passive pressure-volume curves. To test this hypothesis, we studied the effect of increasing EPAP during pressure-controlled modes of NIV in 30 long-term ventilator users (10 each with scoliosis, obesity hypoventilation or neuromuscular disorders). While maintaining the same IPAP, addition of 5 cmH₂O of EPAP reduced mean V_t by 167 ml; 10 cmH₂O reduced V_t by 367 ml. This pattern was seen in all three patient groups. EPAP has several potential advantages, for example maintaining upper airway patency, preventing basal atelectasis and facilitating triggering. EPAP does, however, appear to reduce V_t. Decreasing EPAP is an alternative to increasing IPAP if measurements of gas exchange during NIV indicate that ventilation is inadequate.

Long-term non-invasive ventilation in muscular dystrophy

Long-term non-invasive ventilation (NIV) was introduced in the 1980s, initially mainly for patients with poliomyelitis, muscular dystrophy (MD) or scoliosis. The obesity-hypoventilation syndrome has since become the commonest reason for referral to most centres providing home-NIV. Patients with MD are numerically a much smaller part of the workload, but as their disease progresses the need for ventilatory support changes and they require regular comprehensive assessment of their condition. We have examined the trend in MD use of home-NIV in our unit over the last 25 years. The number of new referrals appears to be stabilizing at around 20-25 over a 5-year period, equivalent to approximately 0.5 per 100,000 of population per year. The mean age at commencement of home-NIV is now 37.5 years, with 5-year survival rates of 70-75%. Ten-year survival rates are just over 40%. The distance of usual place of residence from our unit is fairly stable, currently at a mean of 27 km. Excellent survival rates mean that patients with MD, while numerically small, are likely to remain an important part of the workload of centres providing home-NIV. Our data should prove useful in the planning of future services for this group of patients.

The indications, efficacy and adverse events of rituximab in a large cohort of patients with juvenile-onset SLE

Background

B cells drive antibody formation and T cell activation. This study aimed to describe the clinical indications, efficacy and adverse events (AEs) for the B-cell depleting agent, rituximab, in a large cohort of children with lupus.

Methods

Prescribing records and the UK JSLE Cohort Study database identified rituximab use.

Results

Sixty-three patients received 104 courses of intravenous rituximab over a 10-year period. Patients were aged 12.2 (IQR 9.0–13.9) years at diagnosis and 50 (79%) were female. They had disease for 1.4 (0.2–3.0) years at the time of rituximab. Lupus nephritis was the most common indication (36% of first courses). Clinical biomarkers, 2.5 (1.6–4.3) months after treatment, demonstrated a statistically significant improvement in ESR, C3, C4, creatinine, albumin, haemoglobin, anti-dsDNA titres and urine albumin:creatinine ratio. IgG, IgA and IgM levels decreased ( p < 0.01). Oral corticosteroid dose significantly reduced after rituximab (dose before 0.26 (0.09–0.44) mg/kg, after 0.17 (0.09–0.30) mg/kg; p = 0.01)). AEs occurred in 19 (18%) of all courses including; delayed second dose (8%), Ig replacement (2%) and infusion reactions (6%; anaphylaxis 2%). The global BILAG score showed a trend toward improvement (before 4.5 (2.0–9.0), after 3.0 (2.0–5.0); p = 0.16).

Conclusion

Rituximab improves disease activity in children with lupus and serious AEs are infrequent. Controlled studies are required.

New insights into the pathogenesis and management of lupus in children

Systemic lupus erythematosus (SLE) is the archetypal systemic autoimmune disease, characterised by inflammation causing a wide spectrum of major clinical manifestations that may affect any organ. Childhood-onset SLE (cSLE) is more severe with greater damage and drug burden than adult-onset SLE. Understanding the pathogenesis of cSLE is a key step in directing medical management. The dysregulated immune system, that in health is usually vital in protecting the body from infection, contributes significantly to the disease process. Improved knowledge of disease mechanism will help to identify potential targets for novel agents and the identification of new biomarkers of disease activity. This review will present current knowledge of the innate and adaptive immune responses in cSLE and the optimal patient management that aims to control the disease. Innate immune dysregulation includes the overexpression of interferon-α, dendritic cell activation, neutrophil extracellular traps and phagocyte abnormalities. The classical adaptive immune system is over activated in lupus with excessive autoantibody production due to abnormalities in B and T cell regulation. Novel biologic medications are being developed to specifically target these areas with the ultimate aim of improving the long-term outlook and quality of life for children living with Lupus.

Unmet needs in the measurement of blood pressure in primary care

BACKGROUND

Blood pressure (BP) monitoring in UK children at risk of hypertension takes place predominantly in secondary and tertiary care.

OBJECTIVES

To investigate (i) the availability of paediatric BP equipment in primary care (PC) and (ii) the confidence of PC professionals in measuring and interpreting children's BP.

METHODS

103 PC practices were approached to complete a questionnaire. BP equipment availability and confidence with BP measurement and interpretation were recorded (interval scale 1-10). Cuff size and equipment type were documented.

RESULTS

95 (92%) practices responded; 40/95 possessed paediatric BP cuffs. 35/51 devices were validated for paediatric use. Median (IQR) confidence in BP measurement was 7 (2-8). Confidence in BP interpretation was 3 (2-6), though this improved if normal ranges were provided (8 (6-9), p<0.01).

CONCLUSIONS

Investment in appropriate equipment and education is required to allow PC to successfully monitor BP in children.