Congenitally Corrected Transposition of the Great Arteries in Utero: Morphological Spectrum, Outcomes and Pitfalls in Fetal Diagnosis

Congenitally corrected transposition of the great arteries (ccTGA) is a rare malformation with diverse morphology. We assessed features of fetuses with ccTGA and evaluated neonatal and pediatric outcomes. This was a retrospective review of fetuses with ccTGA at Birmingham Women's and Children's Hospital born from 2005 to 2019. Of thirty-six fetuses identified, six had unavailable prenatal data, one was postnatally diagnosed with isomerism and 29 fetuses were evaluated. ccTGA without associated cardiac lesions was found in 28% (8/29), ccTGA with significant VSD in 31% (9/29), ccTGA with pulmonary obstruction in 24% (7/29) and ccTGA with complex anomalies in 17% (5/29). Tricuspid regurgitation (TR) was observed in 17% (5/29) and heart block (HB) in 10% (3/29) prenatally. Six, that is 21% underwent genetic testing of which one was abnormal. Five extra-cardiac anomalies were reported prenatally and postnatally. Pregnancy was discontinued in five, of which two had moderate TR. There were thirty-one liveborn. Coarctation of the aorta was found in five postnatally but not suspected prenatally. In one, pulmonary stenosis was underestimated; otherwise, prenatal morphology was confirmed. Cardiac interventions were performed in 77% (24/31) liveborn with 39% (12/31) undergoing neonatal intervention. Overall, 6/31 liveborn died including all three with prenatal heart block and one with TR. Estimated survival for all liveborn at 1, 5 and 10 years was 87% (95% CI 76-100%), 83% (95% CI 72-98%) and 80% (95% CI 66-96%) respectively. Accurate prenatal diagnosis of ccTGA is critical for counseling. Early outcomes are favorable with 77% of liveborn undergoing surgery. Fetuses with prenatal diagnosis of complex associated abnormalities, HB and TR appear to do less well.

Why are medical students so motivated to learn ultrasound skills? A qualitative study

BACKGROUND

The introduction of ultrasound (US) courses into medical undergraduate courses is usually met with a particularly high level of student motivation. The reasons for this are unclear. The aim of this study was to investigate the factors that contribute to undergraduate medical students' motivation to learn US skills. Understanding what motivates students to learn US will inform the efforts of faculty to foster students' motivation to learn.

METHODS

We carried out in-depth semi-structured one-to-one interviews with medical students participating in an optional US course at two Swiss universities. The interview guide consisted of 10 main questions. The content was informed by experts in the field of medical education and US, as well as by a literature review of motivation theories for learning, in particular by self-determination theory (SDT). SDT was used to guide the development of the interview guide and to reflect on the resulting themes in the discussion section. The interview guide was piloted with two medical students. The interviews lasted an average of 45 min and were audio recorded and transcribed. Thematic analysis was used to analyse the data.

RESULTS

Fourteen undergraduate medical students in their preclinical (year 3) and clinical studies (years 4 and 5) elaborated on a wide range of reasons for their high motivation to learn US. They were motivated for US training because of the positive nimbus of the US modality, emphasising the advantages of visualisation. Students acknowledged the potential professional benefits of learning US and described it as a fun, exciting group activity.

CONCLUSIONS

The four themes we found in our analysis can all be related to the three universal needs described in SDT. The strong focus on the visual aspect and the positive nimbus of the modality goes beyond that and reflects the visuo-centric Zeitgeist, which claims the superiority of visual information over other data. Educators should be aware that motivation to learn is affected by the Zeitgeist and ensuing preconceptions, such as the perception of the positive nimbus surrounding a topic. Other key elements that can be implemented to motivate students are just-in-time feedback, enabling group experiences and creating awareness of the clinical relevance of learning content.

A retrospective multicentre clinical study on management of isolated splenic vein thrombosis: risks and benefits of anticoagulation

INTRODUCTION

Isolated splenic vein thrombosis (iSVT) is a common complication of pancreatic disease. Whilst patients remain asymptomatic, there is a risk of sinistral portal hypertension and subsequent bleeding from gastric varices if recanalisation does not occur. There is wide variation of iSVT treatment, even within single centres. We report outcomes of iSVT from tertiary referral hepatobiliary and pancreatic (HPB) units including the impact of anticoagulation on recanalisation rates and subsequent variceal bleeding risk.

METHODS

A retrospective cohort study including all patients diagnosed with iSVT on contrast-enhanced CT scan abdomen and pelvis between 2011 and 2019 from two institutions. Patients with both SVT and portal vein thrombosis at diagnosis and isolated splenic vein thrombosis secondary to malignancy were excluded. The outcomes of anticoagulation, recanalisation rates, risk of bleeding and progression to portal vein thrombosis were examined using CT scan abdomen and pelvis with contrast.

RESULTS

Ninety-eight patients with iSVT were included, of which 39 patients received anticoagulation (40%). The most common cause of iSVT was acute pancreatitis n = 88 (90%). The recanalisation rate in the anticoagulation group was 46% vs 15% in patients receiving no anticoagulation (p = 0.0008, OR = 4.7, 95% CI 1.775 to 11.72). Upper abdominal vascular collaterals (demonstrated on CT scan angiography) were significantly less amongst patients who received anticoagulation treatment (p = 0.03, OR = 0.4, 95% CI 0.1736 to 0.9288). The overall rate of upper GI variceal-related bleeding was 3% (n = 3/98) and it was independent of anticoagulation treatment. Two of the patients received therapeutic anticoagulation.

CONCLUSION

The current data supports that therapeutic anticoagulation is associated with a statistically significant increase in recanalisation rates of the splenic vein, with a subsequent reduction in radiological left-sided portal hypertension. However, all patients had a very low risk of variceal bleeding regardless of anticoagulation. The findings from this retrospective study should merit further investigation in large-scale randomised clinical trials.

Beyond forced telehealth adoption: A framework to sustain telehealth among allied health services

INTRODUCTION

As COVID-19 restrictions reduce globally, services will determine what components of care will continue via telehealth. We aimed to determine the clinician, service, and system level factors that influence sustained use of telehealth and develop a framework to enhance sustained use where appropriate.

METHODS

This study was conducted across 16 allied health departments over four health service facilities (Brisbane, Australia). It used a multi-method observational study design, involving telehealth service activity data from hospital administrative databases and qualitative interviews with allied health staff (n  =  80). Data were integrated and analysed using Greenhalgh's Non-adoption, Abandonment, Scale-up, Spread, and Sustainability framework.

RESULTS

Increased telehealth use during the peak COVID period reverted to in-person activity as restrictions eased. Telehealth is unlikely to be sustained without a clear strategy including determination of roles and responsibilities across the organisation. Clinician resistance due to forced adoption remains a key issue. The main motivator for clinicians to use telehealth was improved consumer-centred care. Benefits beyond this are needed to sustain telehealth and improvements are required to make the telehealth experience seamless for providers and recipients. Data were synthesised into a comprehensive framework that can be used as a blueprint for system-wide improvements and service enhancement or redesign.

DISCUSSION

Sustainability of telehealth activity beyond the peak COVID period is unlikely without implementation strategies to address consumer, clinician, service, and system factors. The framework can inform how these strategies can be enacted. Whilst developed for allied health disciplines, it is likely applicable to other disciplines.

Analysis of the limited M. tuberculosis accessory genome reveals potential pitfalls of pan-genome analysis approaches

Pan-genome analysis is a fundamental tool in the study of bacterial genome evolution. Benchmarking the accuracy of pan-genome analysis methods is challenging, because it can be significantly influenced by both the methodology used to compare genomes, as well as differences in the accuracy and representativeness of the genomes analyzed. In this work, we curated a collection of 151 Mycobacterium tuberculosis (Mtb) isolates to evaluate sources of variability in pan-genome analysis. Mtb is characterized by its clonal evolution, absence of horizontal gene transfer, and limited accessory genome, making it an ideal test case for this study. Using a state-of-the-art graph-genome approach, we found that a majority of the structural variation observed in Mtb originates from rearrangement, deletion, and duplication of redundant nucleotide sequences. In contrast, we found that pan-genome analyses that focus on comparison of coding sequences (at the amino acid level) can yield surprisingly variable results, driven by differences in assembly quality and the softwares used. Upon closer inspection, we found that coding sequence annotation discrepancies were a major contributor to inflated Mtb accessory genome estimates. To address this, we developed panqc, a software that detects annotation discrepancies and collapses nucleotide redundancy in pan-genome estimates. We characterized the effect of the panqc adjustment on both pan-genome analysis of Mtb and E. coli genomes, and highlight how different levels of genomic diversity are prone to unique biases. Overall, this study illustrates the need for careful methodological selection and quality control to accurately map the evolutionary dynamics of a bacterial species.

Limitations of antifungal prophylaxis in preventing invasive Candida surgical site infections after liver transplant surgery

Invasive primary Candida surgical site infections (IP-SSIs) are a common complication of liver transplantation, and targeted antifungal prophylaxis is an efficient strategy to limit their occurrence. We performed a retrospective single-center cohort study among adult single liver transplant recipients at Duke University Hospital in the period between 1 January 2015 and 31 December 2020. The study aimed to determine the rate of Candida IP-SSI according to the peri-transplant antifungal prophylaxis received. Of 470 adult single liver transplant recipients, 53 (11.3%) received micafungin prophylaxis, 100 (21.3%) received fluconazole prophylaxis, and 317 (67.4%) did not receive systemic antifungal prophylaxis in the peri-transplant period. Ten Candida IP-SSIs occurred among 5 of 53 (9.4%) micafungin recipients, 1 of 100 (1.0%) fluconazole recipients, and 4 of 317 (1.3%) recipients who did not receive antifungal prophylaxis. Our study highlights the limitations of antifungal prophylaxis in preventing invasive Candida IP-SSI after liver transplant surgery. We hypothesize that pathogen, host, and pharmacokinetic-related factors contributed to the occurrence of Candida IP-SSI despite antifungal prophylaxis. Our study reinforces the need for a risk-based, multi-pronged approach to fungal prevention, including targeted antifungal administration in patients with risks for invasive candidiasis and close monitoring, especially among patients with surgically complex procedures, with timely control of surgical leaks.

What would primary care practitioners do differently after a delayed cancer diagnosis? Learning lessons from their experiences

OBJECTIVE

Diagnosis of cancer is challenging in primary care due to the low incidence of cancer cases in primary care practice. A prolonged diagnostic interval may be due to doctor, patient or system factors, or may be due to the characteristics of the cancer itself. The objective of this study was to learn from Primary Care Physicians' (PCP) experiences of incidents when they had failed to think of, or act on, a cancer diagnosis.

DESIGN

A qualitative, online survey eliciting PCP narratives. Thematic analysis was used to analyse the data.

SETTING AND SUBJECTS

A primary care study, with narratives from 159 PCPs in 23 European countries.

MAIN OUTCOME MEASURES

PCPs' narratives on the question 'If you saw this patient with cancer presenting in the same way today, what would you do differently?

RESULTS

The main themes identified were: thinking broadly; improvement in communication and clinical management; use of other available resources and 'I wouldn't do anything differently'.

CONCLUSION (IMPLICATIONS)

To achieve more timely cancer diagnosis, PCPs need to provide a long-term, holistic and active approach with effective communication, and to ensure shared decision-making, follow-up and continuing re-assessment of the patients' clinical conditions.

Optimal timing of faculty teaching when combined with near-peer teaching: A mixed methods analysis

BACKGROUND

Near-peer teaching is increasingly used in medical education, supporting or replacing faculty teaching. It has positive aspects for learners and tutors, some of which are explained by higher social and cognitive congruence between learners and near-peer tutors (NPTs). This study investigates the optimal combination of faculty tutors (FTs) and NPTs in an abdominal ultrasound course.

METHODS

Sixty-four third-year medical students underwent a basic ultrasound course, with 75% of lessons taught by NPTs and 25% by FTs. Each of four groups had a different faculty teaching timing. A mixed methods approach used a survey and semi-structured interviews at the course end to elicit learners' preferences, and end-of-course examination scores to look for differences in outcomes.

RESULTS

Most learners preferred having faculty teaching in the second half of the course, saying it would be overwhelming to start with FTs. Learners preferred between a quarter and a third of the teaching to be from FTs, with NPTs rated better at teaching basics, and FTs contributing unique, helpful clinical knowledge. There was no significant between-group difference in examination scores.

CONCLUSIONS

Medical students preferred most of their teaching to be from NPTs, with some faculty input in the second half of the course.

Exploring why European primary care physicians sometimes do not think of, or act on, a possible cancer diagnosis. A qualitative study

BACKGROUND

While primary care physicians (PCPs) play a key role in cancer detection, they can find cancer diagnosis challenging, and some patients have considerable delays between presentation and onward referral.

AIM

To explore European PCPs' experiences and views on cases where they considered that they had been slow to think of, or act on, a possible cancer diagnosis.

DESIGN & SETTING

A multicentre European qualitative study, based on an online survey with open-ended questions, asking PCPs for their narratives about cases when they had missed a diagnosis of cancer.

METHOD

Using maximum variation sampling, PCPs in 23 European countries were asked to describe what happened in a case where they were slow to think of a cancer diagnosis, and for their views on why it happened. Thematic analysis was used to analyse the data.

RESULTS

A total of 158 PCPs completed the questionnaire. The main themes were as follows: patients' descriptions did not suggest cancer; distracting factors reduced PCPs' cancer suspicions; patients' hesitancy delayed the diagnosis; system factors not facilitating timely diagnosis; PCPs felt that they had acted wrongly; and problems with communicating adequately.

CONCLUSION

The study identified six overarching themes that need to be addressed. Doing so should reduce morbidity and mortality in the small proportion of patients who have a significant, avoidable delay in their cancer diagnosis. The 'Swiss cheese' model of accident causation showed how the themes related to each other.

Safe Today, Unsafe Tomorrow: Tanzanian Households Experience Variability in Drinking Water Quality

Measuring Escherichia coli in a single-grab sample of stored drinking water is often used to characterize drinking water quality. However, if water quality exhibits variability temporally, then one-time measurement schemes may be insufficient to adequately characterize the quality of water that people consume. This study uses longitudinal data collected from 193 households in peri-urban Tanzania to assess variability in stored water quality and to characterize uncertainty with different data collection schemes. Households were visited 5 times over the course of a year. At each visit, information was collected on water management practices, and a sample of stored drinking water was collected for E. coli enumeration. Water quality was poor for households, with 80% having highly contaminated (>100 CFU per 100 mL) water during at least one visit. There was substantial variability of water quality for households, with only 3% of households having the same category (low, medium, or high) of water quality for all five visits. These data suggest a single sample would inaccurately characterize a household's drinking water quality over the course of a year and lead to misestimates of population level access to safe drinking water.

Predictors of hospitalisation and recovery following full antipsychotic discontinuation in first episode psychosis. A naturalistic retrospective cohort study

Whilst antipsychotic medication reduces risk of relapse following a first episode of psychosis (FEP), some individuals can discontinue medication and remain relapse free. We aimed to identify patient and service-specific factors which influence clinical outcome following antipsychotic discontinuation. The outcomes 'admission to hospital' and 'remaining free from psychotic symptoms', both within one year from discontinuation, were explored retrospectively in an established naturalistic cohort of 354 patients with FEP. Logistic regression analysis was used to explore influence of routinely available baseline and treatment course variables on these outcomes. Seventy-seven individuals (22 %) fully discontinued antipsychotic treatment within a year, at mean 102 days from initiation. Only antipsychotic type had significant association with discontinuation; aripiprazole was discontinued more than olanzapine (p = 0.028). Seventeen individuals required admission to hospital; significantly associated with prior admission at first illness onset (p = 0.004), and prior legal detention to hospital (p = 0.001). Admission was less likely in those discontinuing aripiprazole vs olanzapine (p = 0.044). Twenty-four patients remained psychosis symptom free and were most significantly likely to have received clinician support in discontinuation; this group had no association with either initial duration of untreated psychosis or prior duration of antipsychotic treatment. Future studies exploring outcomes following antipsychotic discontinuation require consistency of choice of outcome measures and sample stratification by vulnerability factors including severity of first illness episode, whether remaining symptom free after first episode, which medication switched from and baseline functioning. The impact and nature of clinician support to discontinue requires further exploration alongside its association with abruptness of discontinuation.

Insulin sensitization by hepatic FoxO deletion is insufficient to lower atherosclerosis in mice

Background–

Type 2 diabetes is associated with an increased risk of atherosclerotic cardiovascular disease. It has been suggested that insulin resistance underlies this link, possibly by altering the functions of cells in the artery wall. We aimed to test whether improving systemic insulin sensitivity reduces atherosclerosis.

Methods–

We used mice that are established to have improved systemic insulin sensitivity: those lacking FoxO transcription factors in hepatocytes. Three hepatic FoxO isoforms (FoxO1, FoxO3, and FoxO4) function together to promote hepatic glucose output, and ablating them lowers glucose production, lowers circulating glucose and insulin, and improves systemic insulin sensitivity. We made these mice susceptible to atherosclerosis in two different ways, by injecting them with gain-of-function AAV8.mPcsk9D377Y and by crossing with Ldlr-/- mice.

Results–

We verified that hepatic FoxO ablation improves systemic insulin sensitivity in these atherosclerotic settings. We observed that FoxO deficiency caused no reductions in atherosclerosis, and in some cases increased atherosclerosis. These phenotypes coincided with large increases in circulating triglycerides in FoxO-ablated mice.

Conclusions–

These findings suggest that systemic insulin sensitization is insufficient to reduce atherosclerosis.

A new portable field rotational viscometer for high-temperature melts

Mounted on top of furnaces, laboratory viscometers can be used for the rheological characterization of high temperature melts, such as molten rocks (lava). However, there are no instruments capable of measuring the viscosity of large volumes of high temperature melts outside the laboratory at, for example, active lava flows on volcanoes or at industrial sites. In this article, we describe a new instrument designed to be easy to operate, highly mobile, and capable of measuring the viscosity of high temperature liquids and suspensions (<1350 °C). The device consists of a torque sensor mounted in line with a stainless-steel shear vane that is immersed in the melt and driven by a motor that rotates the shear vane. In addition, a thermocouple placed between the blades of the shear vane measures the temperature of the melt at the measurement location. An onboard microcomputer records torque, rotation rate, and temperature simultaneously and in real time, thus enabling the characterization of the rheological flow curve of the material as a function of temperature and strain rate. The instrument is calibrated using viscosity standards at low temperatures (20-60 °C) and over a wide range of stress (30-3870 Pa), strain rate (0.1-27.9 s-1), and viscosity (10-650 Pa s). High temperature tests were performed in large scale experiments within ∼25 l of lava at temperatures between 1000 and 1350 °C to validate the system's performance for future use in natural lava flows. This portable field viscometer was primarily designed to measure the viscosity of geological melts at their relevant temperatures and in their natural state on the flanks of volcanoes, but it could also be used for industrial purposes and beyond.

Primary care practitioners' priorities for improving the timeliness of cancer diagnosis in primary care: a European cluster-based analysis

BACKGROUND

Diagnosing cancer at an early stage increases the likelihood of survival, and more advanced cancers are more difficult to treat successfully. Primary care practitioners (PCPs) play a key role in timely diagnosis of cancer. PCPs' knowledge of their own patient populations and health systems could help improve the planning of more effective approaches to earlier cancer recognition and referral. How PCPs act when faced with patients who may have cancer is likely to depend on how their health systems are organised, and this may be one explanation for the wide variation on cancer survival rates across Europe.

OBJECTIVES

To identify and characterise clusters of countries whose PCPs perceive the same factors as being important in improving the timeliness of cancer diagnosis.

METHODS

A cluster analysis of qualitative data from an online survey was carried out. PCPs answered an open-ended survey question on how the speed of diagnosis of cancer in primary care could be improved. Following coding and thematic analysis, we identified the number of times per country that an item in a theme was mentioned. k-means clustering identified clusters of countries whose PCPs perceived the same themes as most important. Post-hoc testing explored differences between these clusters.

SETTING

Twenty-five primary care centres in 20 European countries. Each centre was asked to recruit at least 50 participants.

PARTICIPANTS

Primary care practitioners of each country.

RESULTS

In all, 1,351 PCPs gave free-text answers. We identified eighteen themes organising the content of the responses. Based on the frequency of the themes, k-means clustering identified three groups of countries. There were significant differences between clusters regarding the importance of: access to tests (p = 0.010); access to specialists (p = 0.014), screening (p < 0.001); and finances, quotas & limits (p < 0.001).

CONCLUSIONS

Our study identified three distinct clusters of European countries within which PCPs had similar views on the factors that would improve the timeliness of cancer diagnosis. Further work is needed to understand what it is about the clusters that have produced these patterns, allowing healthcare systems to share best practice and to reduce disparities.

Lineage classification and antitubercular drug resistance surveillance of Mycobacterium tuberculosis by whole-genome sequencing in Southern India

Whole-genome sequencing has created a revolution in tuberculosis management by providing a comprehensive picture of the various genetic polymorphisms with unprecedented accuracy. Studies mapping genomic heterogeneity in clinical isolates of Mycobacterium tuberculosis using a whole-genome sequencing approach from high tuberculosis burden countries are underrepresented. We report whole-genome sequencing results of 242 clinical isolates of culture-confirmed M. tuberculosis isolates from tuberculosis patients referred to a tertiary care hospital in Southern India. Phylogenetic analysis revealed that the isolates in our study belonged to five different lineages, with Indo-Oceanic (lineage 1, n = 122) and East-African Indian (lineage 3, n = 80) being the most prevalent. We report several mutations in genes conferring resistance to first and second line antitubercular drugs including the genes rpoB, katG, ahpC, inhA, fabG1, embB, pncA, rpsL, rrs, and gyrA. The majority of these mutations were identified in relatively high proportions in lineage 1. Our study highlights the utility of whole-genome sequencing as a potential supplemental tool to the existing genotypic and phenotypic methods, in providing expedited comprehensive surveillance of mutations that may be associated with antitubercular drug resistance as well as lineage characterization of M. tuberculosis isolates. Further larger-scale whole-genome datasets with linked minimum inhibition concentration testing are imperative for resolving the discrepancies between whole-genome sequencing and phenotypic drug sensitivity testing results and quantifying the level of the resistance associated with the mutations for optimization of antitubercular drug and precise dose selection in clinics. IMPORTANCE Studies mapping genetic heterogeneity of clinical isolates of M. tuberculosis for determining their strain lineage and drug resistance by whole-genome sequencing are limited in high tuberculosis burden settings. We carried out whole-genome sequencing of 242 M. tuberculosis isolates from drug-sensitive and drug-resistant tuberculosis patients, identified and collected as part of the TB Portals Program, to have a comprehensive insight into the genetic diversity of M. tuberculosis in Southern India. We report several genetic variations in M. tuberculosis that may confer resistance to antitubercular drugs. Further wide-scale efforts are required to fully characterize M. tuberculosis genetic diversity at a population level in high tuberculosis burden settings for providing precise tuberculosis treatment.

The challenges faced by early career international medical graduates in general practice and opportunities for supporting them: a rapid review

BACKGROUND

British general practice is facing a workforce crisis against a backdrop of an ageing population experiencing increasingly complex health challenges. The NHS must increase the supply of GPs, including international medical graduate (IMG) GPs, by increasing recruitment and retention. IMG GPs face distinct challenges during training and their early careers. Understanding these challenges, as well as the help and support offered to early career IMG GPs, is crucial to building and sustaining the general practice workforce.

AIM

To understand the challenges facing early career IMG GPs and the help and support they can access.

DESIGN & SETTING

Rapid review of studies and grey literature on UK-based IMG GPs.

METHOD

Six databases were searched. Four websites were searched to find grey literature. Titles and abstracts were screened according to inclusion and exclusion criteria, followed by the full study where applicable. The included studies were analysed using a thematic synthesis approach to identify the challenges faced by early career IMG GPs, as well as the help and support available.

RESULTS

The database search yielded 234 studies, with 38 additional studies identified via other methods. Twenty-one studies were included in the synthesis. Seven challenges were identified, as well as a range of help and support available. Early career IMG GPs face a range of psychological, social, and practical challenges, which may not be adequately addressed by the help and support currently offered by the NHS.

CONCLUSION

Further research is required to understand the extent to which early career IMG GPs access the help and support offered, and if it adequately addresses the unique challenges they face.

How Safety Culture Surveys Influence the Quality and Safety of Healthcare Organisations

Objectives Safety culture surveys have been widely used in healthcare for more than two decades predominantly as a tool for measuring the level of safety culture (as defined as the beliefs and attitudes that staff express about how their organisation ought to work and how it does in fact work). However, there is the potential for the survey process itself to influence the safety culture and working practices in departments and organisations. The objective of this study was to identify the mechanism by which these changes might occur. Design, setting and participants Mixed methods combining qualitative semi-structured interviews and quantitative scores from patient safety surveys. This evaluation was conducted across general practice, community and acute hospitals in two NHS regions in England; South West and Greater Manchester. The study was undertaken between 2015 and 2018 during the implementation of a series of Patient Safety Collaboratives. Safety, Communication, Operational Reliability, and Engagement (SCORE) surveys were administered in 15 units, followed by a staff debriefing and a second SCORE survey. Semi-structured interviews were conducted with clinicians (n=61). Results from the first and second surveys were compared in order to test for differences in responses. Sixty-one semi-structured interviews were conducted across participating units and thematically analysed.  Analysis and results Results from the first and second surveys were compared using chi-squared and Fisher's exact tests. Sixty-one semi-structured interviews were conducted across participating units and thematically analysed.  There was little change in responses between the first and second SCORE surveys. Within general practice there was some improvement in responses in three survey domains; however, these differences were not conclusive. The qualitative interview data demonstrated a beneficial effect on safety culture. Staff stated that the survey debriefings created a new safe space where problems could be discussed and improvement plans created.  Conclusions Safety culture surveys can improve safety culture within departments if they are followed by a process that includes debriefing the staff and working with them to develop improvement plans.

Digital divide or digital exclusion? Do allied health professionals' assumptions drive use of telehealth?

INTRODUCTION

Telehealth use within allied health services currently lacks structure and consistency, ultimately affecting who can, and cannot, access services. This study aimed to investigate the factors influencing allied health professionals' (AHP) selection of consumers and appointments for telehealth.

METHODS

This study was conducted across 16 allied health departments from four Australian hospitals. Semi-structured focus groups were conducted with 58 AHPs. Analysis was underpinned by Qualitative Description methodology with inductive coding guided by Braun and Clarke's thematic analysis approach.

RESULTS

Six themes were identified that influenced AHPs' evaluation of telehealth suitability and selection of consumers. These included the following: (1) ease, efficiency and comfort of telehealth for clinicians; (2) clear benefits of telehealth for the consumer, yet the consumers were not always given the choice; (3) consumers' technology access and ability; (4) establishing and maintaining effective therapeutic relationships via telehealth; (5) delivering clinically appropriate and effective care via telehealth; and (6) external influences on telehealth service provision. A further theme of 'assumption versus reality' was noted to pervade all six themes.

DISCUSSION

Clinicians remain the key decision makers for whether telehealth is offered within allied health services. Ease and efficiency of use is a major driver in AHP's willingness to use telehealth. Assumptions and pre-conceived frames-of-reference often underpin decisions to not offer telehealth and present major barriers to telehealth adoption. The development of evidence-based, decision-support frameworks that engage the consumer and clinician in determining when telehealth is used is required. Services need to actively pursue joint decision-making between the clinician and consumer about service delivery preferences.

Combining Radiological and Genomic TB Portals Data for Drug Resistance Analysis

Tuberculosis (TB) drug resistance is a worldwide public health problem. It decreases the likelihood of a positive outcome for the individual patient and increases the likelihood of disease spread. Therefore, early detection of TB drug resistance is crucial for improving outcomes and controlling disease transmission. While drug-sensitive tuberculosis cases are declining worldwide because of effective treatment, the threat of drug-resistant tuberculosis is growing, and the success rate of drug-resistant tuberculosis treatment is only around 60%. The TB Portals program provides a publicly accessible repository of TB case data with an emphasis on collecting drug-resistant cases. The dataset includes multi-modal information such as socioeconomic/geographic data, clinical characteristics, pathogen genomics, and radiological features. The program is an international collaboration whose participants are typically under a substantial burden of drug-resistant tuberculosis, with data collected from standard clinical care provided to the patients. Consequentially, the TB Portals dataset is heterogenous in nature, with data representing multiple treatment centers in different countries and containing cross-domain information. This study presents the challenges and methods used to address them when working with this real-world dataset. Our goal was to evaluate whether combining radiological features derived from a chest X-ray of the host and genomic features from the pathogen can potentially improve the identification of the drug susceptibility type, drug-sensitive (DS-TB) or drug-resistant (DR-TB), and the length of the first successful drug regimen. To perform these studies, significantly imbalanced data needed to be processed, which included a much larger number of DR-TB cases than DS-TB, many more cases with radiological findings than genomic ones, and the sparse high dimensional nature of the genomic information. Three evaluation studies were carried out. First, the DR-TB/DS-TB classification model achieved an average accuracy of 92.4% when using genomic features alone or when combining radiological and genomic features. Second, the regression model for the length of the first successful treatment had a relative error of 53.5% using radiological features, 25.6% using genomic features, and 22.0% using both radiological and genomic features. Finally, the relative error of the third regression model predicting the length of the first treatment using the most common drug combination varied depending on the feature type used. When using radiological features alone, the relative error was 17.8%. For genomic features alone, the relative error increased to 19.9%. The model had a relative error of 19.0% when both radiological and genomic features were combined. Although combining radiological and genomic features did not improve upon the use of genomic features when classifying DR-TB/DS-TB, the combination of the two feature types improved the relative error of the predictive model for the length of the first successful treatment. Furthermore, the regression model trained on radiological features achieved the best performance when predicting the treatment length of the most common drug combination.

Tumor-Derived CCL5 Recruits Cancer-Associated Fibroblasts and Promotes Tumor Cell Proliferation in Esophageal Squamous Cell Carcinoma

Cancer-associated fibroblasts (CAF) can promote tumor growth, metastasis, and therapeutic resistance in esophageal squamous cell carcinoma (ESCC), but the mechanisms of action remain elusive. Our objective was to identify secreted factor(s) that mediate the communication between CAFs and ESCC tumor cells with the aim of identifying potential druggable targets. Through unbiased cytokine arrays, we have identified CC motif chemokine ligand 5 (CCL5) as a secreted factor that is increased upon co-culture of ESCC cells and CAFs, which we replicated in esophageal adenocarcinoma (EAC) with CAFs. Loss of tumor-cell-derived CCL5 reduces ESCC cell proliferation in vitro and in vivo and we propose this is mediated, in part, by a reduction in ERK1/2 signaling. Loss of tumor-derived CCL5 reduces the percentage of CAFs recruited to xenograft tumors in vivo. CCL5 is a ligand for the CC motif receptor 5 (CCR5), for which a clinically approved inhibitor exists, namely Maraviroc. Maraviroc treatment reduced tumor volume, CAF recruitment, and ERK1/2 signaling in vivo, thus, mimicking the effects observed with genetic loss of CCL5. High CCL5 or CCR5 expression is associated with worse prognosis in low-grade esophageal carcinomas.

IMPLICATIONS

These data highlight the role of CCL5 in tumorigenesis and the therapeutic potential of targeting the CCL5-CCR5 axis in ESCC.

OGFOD1 modulates the transcriptional and proteomic landscapes to alter isoproterenol-induced hypertrophy susceptibility

Cardiac hypertrophy is associated with increased translation. However, little is known of the mechanisms that regulate translation in hypertrophy. Members of the 2-oxoglutarate-dependent dioxygenase family regulate several aspects of gene expression, including translation. An important member of this family is OGFOD1. Here, we show OGFOD1 accumulates in failing human hearts. Upon OGFOD1 deletion, murine hearts showed transcriptomic and proteomic changes, with only 21 proteins and mRNAs (0.6%) changing in the same direction. Additionally, OGFOD1-KO mice were protected from induced hypertrophy, supporting a role for OGFOD1 in the cardiac response to chronic stress.

Medium-term Outcome of Prenatally Diagnosed Hypoplastic Left-Heart Syndrome and Impact of a Restrictive Atrial Septum Diagnosed in-utero

OBJECTIVE

Surgical outcome data differs from overall outcomes of prenatally diagnosed fetuses with hypoplastic left heart syndrome (HLHS). Our aim was to describe outcome of prenatally diagnosed fetuses with this anomaly.

METHODS

Retrospective review of prenatally diagnosed classical HLHS at a tertiary hospital over a 13-year period, estimated due dates 01/08/2006 to 31/12/2019. HLHS-variants and ventricular disproportion were excluded.

RESULTS

203 fetuses were identified with outcome information available for 201. There were extra-cardiac abnormalities in 8% (16/203), with genetic variants in 14% of those tested (17/122). There were 55 (27%) terminations of pregnancy, 5 (2%) intrauterine deaths and 10 (5%) babies had prenatally planned compassionate care. There was intention to treat (ITT) in the remaining 131/201(65%). Of these, there were 8 neonatal deaths before intervention, two patients had surgery in other centers. Of the other 121 patients, Norwood procedure performed in 113 (93%), initial hybrid in 7 (6%), and 1 had palliative coarctation stenting. Survival for the ITT group from birth at 6-months, 1-year and 5-years was 70%, 65%, 62% respectively. Altogether of the initial 201 prenatally diagnosed fetuses, 80 patients (40%) are currently alive. A restrictive atrial septum (RAS) is an important sub-category associated with death, HR 2.61, 95%CI 1.34-5.05, p = 0.005, with only 5/29 patients still alive.

CONCLUSION

Medium-term outcomes of prenatally diagnosed HLHS have improved however it should be noted that almost 40% do not get to surgical palliation, which is vital to those doing fetal counselling. There remains significant mortality particularly in fetuses with in-utero diagnosed RAS.

Making sense of the paediatric ECG: ST segments

This is a follow on article on different aspects of paediatric ECG interpretation.

Comparative Effectiveness of Integrated Peer Support and Clinical Staffing Models for Community-Based Residential Mental Health Rehabilitation: A Prospective Observational Study

This observational study compared the outcomes of consumers receiving community-based residential mental health rehabilitation support in Australia under a clinical staffing model and an integrated staffing model where Peer Support Workers are the majority component of the staffing profile. Reliable and clinically significant (RCS) change between admission and discharge in functional and clinical assessment measures were compared for consumers receiving care under the clinical (n = 52) and integrated (n = 93) staffing models. Covariate analyses examined the impact of known confounders on the outcomes of the staffing model groups. No statistically significant differences in RCS improvement were identified between the staffing models. However, logistic regression modelling showed that consumers admitted under the integrated staffing model were more likely to experience reliable improvement in general psychiatric symptoms and social functioning. The findings support the clinical and integrated staffing models achieving at least equivalent outcomes for community-based residential rehabilitation services consumers.

A68 HOW REAL ARE YOUR SURVEY RESPONDENTS? IDENTIFYING FRAUDULENT RESPONDENTS IN ONLINE SURVEYS – A CASE EXAMPLE IN INFLAMMATORY BOWEL DISEASE (IBD)

Background

Social media and online surveys are commonly used to recruit and collect data from patients and physicians about GI diseases – they are efficient, convenient, and less resource intensive compared to traditional recruitment approaches and paper surveys. However, online data fraud is increasing and difficult to identify. Online data fraud can include intentional duplicate responses/straight-lining/inattention, bots/malicious software, and professional survey takers who provide fraudulent responses to meet study eligibility.

Purpose

1) Illustrate challenges of identifying fraudulent respondents through an algorithm and verification process we developed for our survey in IBD. 2) Demonstrate potential impact of fraudulent respondents on data and results.

Method

Online survey of Canadian adults (>18 years) with IBD about healthcare processes for managing IBD hosted using Qualtrics. Recruitment was done in clinic and online (mailing lists, social media). A $25 giftcard was offered for participation due to low response after 3 months in field, after which a large influx of ‘respondents’ occurred. Most were fraudulent although not obvious at first. To mitigate further fraudulent responses, we added the following to our survey: reCAPTCHA score, repeated question (year of IBD diagnosis), duplicate ID score, fraud score and honeypot question.

Our algorithm to identify fraudulent responses included 13 binary ‘red flag’ variables: age <18 years, year of diagnosis < year of birth, 2 different year of diagnosis, invalid postal code, survey duration <10 minutes, survey duration 10-15 minutes, suspicious comments for open text questions (x2), duplicate email, suspicious email, duplicate ID score ≥30, fraud score ≥30, and failed honeypot question. These variables were used to generate a fraudulent response score (range: 0-13; 13=most likely fraudulent). ‘Respondents’ with scores >3 were categorized as likely fraudulent. Respondents with scores ≤3 were reviewed individually. Respondents flagged as likely real or unsure were emailed and asked to verify their age; those who correctly verified age were considered likely real and included in the final sample.

Result(s)

Of the 4334 ‘respondents’ who started the survey, based on fraudulent response score we identified 75% (n=3258) as likely fraudulent, 17% (n=727) as unsure and 8% (n=349) as likely real. After age verification, 76% (n=3297) were considered likely fraudulent, 14% (n=592) remained unsure, 10% (n=442) were considered likely real, and <1% (n=3) were duplicates of likely real respondents.

Conclusion(s)

Despite convenience, social media and online surveys can be prone to fraudulent responses, especially when incentives are offered. We developed an algorithm and verification process to identify fraudulent responses using an IBD survey example. Given that only 10% of the full sample was considered likely real, researchers using social media and online surveys should carefully examine data for fraudulent responses and apply strategies to mitigate risks.

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CCC

Disclosure of Interest

None Declared

Transitions from pediatric to adult rheumatology care for juvenile idiopathic arthritis: a patient led qualitative study

Background

Juvenile idiopathic arthritis (JIA) is a childhood autoimmune disease that causes swelling and pain in at least one joint. Young people with JIA experience symptoms that persist into adulthood, and thus will undergo a transition including the o transfer of care from a pediatric rheumatologist an adult rheumatologist. Missing from the literature is research that centres the transition experience of young people with JIA in Canada. This goal of this patient-led research was to explore the experience young people with JIA through the process of transition.

Methods

Qualitative study using the Patient and Community Engaged Research (PaCER) approach. Trained patient-researchers conducted three focus groups using the Set, Collect and Reflect PaCER process. Participants, recruited via purposive and snowball sampling using research/personal networks and social media, were young people with JIA in Canada between 18 and 28 years who had experienced with the process of transition to adult care. Recordings were transcribed verbatim. Patient researchers individually coded overlapping sections of the data, and thematic analysis was conducted.

Results

In total, nine individuals participated in one or more focus groups. Three themes were identified, with sub-themes: preparedness for transition (readiness for the transfer of care, developing self-advocacy skills), continuity and breadth of care (changing relationships, culture shock, new responsibilities), need for support (social support, mental health support, and ongoing support needs – beyond the transfer of care. Peer support was a connecting concept in the support sub-themes. Transition was more than a change in primary physician but also a change in the care model and breadth of care provided, which was challenging for young people especially if they had insufficient information.

Conclusions

Transition from pediatric to adult care in rheumatology is a significant period for young people living with JIA, and this patient-led study provided insight into the experience from the perspective of young people with JIA which is critical to informing the development of supports for patients through the process. Patients, caregivers, pediatric and adult rheumatologists and members of the multi-disciplinary care team need to collaborate in terms of resources preparing for transfer, and support throughout the transition process to ensure a successful transition process.

A gamification-based intervention to encourage active travel

Purpose

‘Beat the Street’ is a community-wide intervention which aims to increase active travel by turning an area into a 6-week game. Residents earn points and prizes by walking and cycling and tapping a smartcard on RFID readers called ‘Beat Boxes’ placed on lampposts at half-mile intervals. To-date, over 1 million people have taken part in the intervention, however, the impact of the program on adult active travel is yet to be explored.

Methods

In Autumn 2019, Beat the Street was delivered throughout the London Borough of Hounslow. Prior, and immediately following the intervention, residents were invited to complete a self-report questionnaire (Sport England Active Lives Survey-SF) to assess changes in physical activity. Time-stamp data generated through Beat Box activity provided an objective measure of intervention engagement and a traffic survey camera was used to measure the number of cars travelling along 1 target road between 1-week pre- and 1-week post-intervention.

Results

28,219 people took part in the six-week game. Between pre- and post-intervention there was 7% decrease in adults reporting less than 30mins of activity per week and a 13% rise in adults reporting 150+ mins (n = 346, p &lt; 0.01). Beat box data ascertained that 25% of total taps at all Beat Boxes were made between 08:00-08:59am and a further 28% were made between 3:00-3:59pm, typical travel to school/work periods. Further, traffic camera data showed that between the week before and week following Beat the Street, 1199 and 705 fewer cars and 130 and 36 fewer vans were observed travelling along Cambridge Road between 07:00-09:30am and 2:00-4:30pm, respectively.

Conclusions

These data sources, in combination, suggest gamification may be an encouraging approach to increasing levels of active travel at a community-wide level.

Key messages

• Gamification based intervention increases physical activity.

• Gamification encourages active travel to school and work.

Trainee doctors' perceptions of the surgeon stereotype and its impact on professional identification: a qualitative study

BACKGROUND

The demography of the medical profession is changing as more women join the workforce. Traditional assumptions about the personal qualities required to be a successful surgeon may change as more women join the specialty. While exploring the attitudes and beliefs of doctors in their second 'Foundation' year of post-graduate training (FY2) about their choice of specialty, evidence emerged about how the stereotype of the surgeon influences professional identification and beliefs about person-specialty fit.

METHODS

Qualitative telephone interviews with 24 FY2 doctors, 17 women and 7 men, in South-West England.

RESULTS

Many participants reported exposure to stereotypes about the personal qualities desirable in a surgeon. Senior doctors and other trainees were the primary source of these stereotypical views. Experience on surgical placements could either reinforce stereotypes or challenge them, the latter particularly where senior surgeons provided positive role models. As more women enter the surgical specialties, they are increasingly challenging the traditional stereotype and sub-culture.

CONCLUSION

Gendered stereotypes about surgical roles persist, and for some this can hinder professional identification with the role. Positive role models and mentoring can encourage and support women who are interested a surgical career to identify with the role, but there is a need for a broader debate encompassing job redesign and surgical identities.

Atomic-Scale View of Protein-PEG Interactions that Redirect the Thermal Unfolding Pathway of PEGylated Human Galectin-3

PEGylation is a promising approach to address the central challenge of applying biologics, i.e., lack of protein stability in the demanding environment of the human body. Wider application is hindered by lack of atomic level understanding of protein-PEG interactions, preventing design of conjugates with predicted properties. We deployed an integrative structural and biophysical approach to address this critical challenge with the PEGylated carbohydrate recognition domain of human galectin-3 (Gal3C), a lectin essential for cell adhesion and potential biologic. PEGylation dramatically increased Gal3C thermal stability, forming a stable intermediate and redirecting its unfolding pathway. Structural details revealed by NMR pointed to a potential role of PEG localization facilitated by charged residues. Replacing these residues subtly altered the protein-PEG interface and thermal unfolding behavior, providing insight into rationally designing conjugates while preserving PEGylation benefits.

Case studies in neuroscience: reversible signatures of edema following electric and piezoelectric craniotomy drilling in macaques

In vivo electrophysiology requires direct access to brain tissue, necessitating the development and refinement of surgical procedures and techniques that promote the health and well-being of animal subjects. Here, we report a series of findings noted on structural magnetic resonance imaging (MRI) scans in monkeys with MRI-compatible implants following small craniotomies that provide access for intracranial electrophysiology. We found distinct brain regions exhibiting hyperintensities in T2-weighted scans that were prominent underneath the sites at which craniotomies had been performed. We interpreted these hyperintensities as edema of the neural tissue and found that they were predominantly present following electric and piezoelectric drilling, but not when manual, hand-operated drills were used. Furthermore, the anomalies subsided within 2-3 wk following surgery. Our report highlights the utility of MRI-compatible implants that promote clinical examination of the animal's brain, sometimes revealing findings that may go unnoticed when incompatible implants are used. We show replicable differences in outcome when using electric versus mechanical devices, both ubiquitous in the field. If electric drills are used, our report cautions against electrophysiological recordings from tissue directly underneath the craniotomy for the first 2-3 wk following the procedure due to putative edema.NEW & NOTEWORTHY Close examination of structural MRI in eight nonhuman primates following craniotomy surgeries for intracranial electrophysiology highlights a prevalence of hyperintensities on T2-weighted scans following surgeries conducted using electric and piezoelectric drills, but not when using mechanical, hand-operated drills. We interpret these anomalies as edema of neural tissue that resolved 2-3 wk postsurgery. This finding is especially of interest as electrophysiological recordings from compromised tissue may directly influence the integrity of collected data immediately following surgery.

183 Improving Documentation of Antibiotic Prophylaxis and Anticoagulation in Vascular Surgery Operation Notes at a Tertiary Centre: A Quality Improvement Project

Aim

Operation notes have important medico-legal implications and should follow the Good Surgical Practice framework to enable continuity of care.

The aim of this quality improvement project was to determine adherence of vascular surgery operation notes to the Good Surgical Practice framework at a tertiary vascular centre, identify areas of improvement and introduce sustainable change to improve patient care.

Method

Two Plan-Do-Study-Act cycles were enacted. A prospective audit was conducted over September 2021 to identify areas of improvement in documentation. The first intervention that was introduced was electronic patient records (EPR). The second intervention introduced was departmental education via posters, regular educational sessions, and presentations.

Results

The prospective audit of 31 operations over September 2021 identified antibiotic prophylaxis was only recorded in 4/31 (13%) and post-operative anticoagulation in 21/31 (68%). A retrospective audit of 28 operations over October 2021 after the introduction of EPR demonstrated improved documentation of antibiotic prophylaxis (16/28, 57%) but no improvement in post-operative anticoagulation documentation (17/28, 61%). Departmental education improved the documentation of antibiotic prophylaxis (18/30, 60%) and post-operative anticoagulation (22/30, 73%).

Conclusions

We have demonstrated that EPR and departmental education can improve operation note documentation and patient care. Next steps include designing vascular surgery proformas to further improve documentation.

[Near-Peers First, Physician Tutors Last. Interim Report of a Mixed-Methods Study Exploring Optimal Timing in Undergraduate Ultrasound Teaching]

Near-Peers First, Physician Tutors Last. Interim Report of a Mixed-Methods Study Exploring Optimal Timing in Undergraduate Ultrasound Teaching Abstract. While many medical undergraduate ultrasound teaching programmes combine teaching from both physician and student ('near-peer') tutors, there has been little research on how these can be optimally combined. In this study, four groups of 16 medical undergraduates each received twelve lessons from student tutors and four lessons from physician tutors as part of their basic ultrasound course. Each group's physician tutor lessons took place in a different quarter of the course timetable. Quantitative and qualitative data were then collected through an online questionnaire, and 15 participants had 1:1 interviews. This interim analysis shows that, when designing combined ultrasound teaching for medical undergraduates, student tutors should be used at the start and physician tutors in the second half of the programme.

App-based intervention for cardiovascular and diabetes risk awareness and prevention

Funding Acknowledgements

Type of funding sources: Public Institution(s). Main funding source(s): Centre for Primary Health Care and Equity, University of New South WalesAustralian e-Health Research Centre, Commonwealth Scientific and Industrial Research Organisation

Background

Cardiovascular disease and type 2 diabetes mellitus are highly prevalent worldwide. They have similar risk factors, and people with diabetes have a two- to threefold increased risk of myocardial infarction and stroke. Many of the risk factors are lifestyle related. Hence, behaviour change interventions have the potential to decrease the risk for cardiovascular disease and type 2 diabetes mellitus.

Purpose

We aimed to develop and evaluate an app-based intervention for the primary prevention of cardiovascular disease and type 2 diabetes mellitus.

Methods

We developed our app using the methodology by Tombor and colleagues for the development of digital behaviour change interventions. We used the Behaviour Change Wheel and embedded 12 behaviour change techniques. The three core modules of the app consisted of i) risk scores for 5-year cardiovascular disease and type 2 diabetes mellitus; ii) goal setting and tracking functions for smoking, alcohol intake, diet, and physical activity; and iii) education about the diseases and risk factors. With the app prototype, we conducted usability testing via an iterative approach. We interviewed the participants and used their feedback to improve the app design. Next, we conducted a feasibility study with the new version to assess whether participants would use the app over three months. We were interested in drop-out from the intervention, adherence to app use, and usability of the app. We received ethics approval for both studies and written consent from all participants.

Results

The usability testing consisted of two rounds. For each round, we had five participants who were on average 57 years old. In the first round, three participants experienced a technical error that stopped them from completing the registration. From those who were able to register, five rated the app as above average according to the System Usability Scale. Overall, the participants found the app easy to use and indicated that they were interested to use it frequently. We included some additional features based on the preferences of the participants in the usability testing. For the feasibility study, we recruited 47 participants aged 45 years and older who were free of cardiovascular disease and type 2 diabetes mellitus at baseline, with a balanced distribution of age (45-64 years and ≥65 years) and gender. From those participants, four withdrew from the study immediately after providing consent and the remainder continued using the app for varying periods of time.

Conclusions

We ensured that the app is based on the theory of behaviour change and scientific evidence. We used a stepwise approach to improve the app design and to test the feasibility of the intervention. The next step will be to develop a framework for a larger trial that implements the intervention into the existing healthcare setting and investigates its effectiveness.

Benchmarking the empirical accuracy of short-read sequencing across the M. tuberculosis genome

MOTIVATION

Short-read whole-genome sequencing (WGS) is a vital tool for clinical applications and basic research. Genetic divergence from the reference genome, repetitive sequences and sequencing bias reduces the performance of variant calling using short-read alignment, but the loss in recall and specificity has not been adequately characterized. To benchmark short-read variant calling, we used 36 diverse clinical Mycobacterium tuberculosis (Mtb) isolates dually sequenced with Illumina short-reads and PacBio long-reads. We systematically studied the short-read variant calling accuracy and the influence of sequence uniqueness, reference bias and GC content.

RESULTS

Reference-based Illumina variant calling demonstrated a maximum recall of 89.0% and minimum precision of 98.5% across parameters evaluated. The approach that maximized variant recall while still maintaining high precision (<99%) was tuning the mapping quality filtering threshold, i.e. confidence of the read mapping (recall = 85.8%, precision = 99.1%, MQ ≥ 40). Additional masking of repetitive sequence content is an alternative conservative approach to variant calling that increases precision at cost to recall (recall = 70.2%, precision = 99.6%, MQ ≥ 40). Of the genomic positions typically excluded for Mtb, 68% are accurately called using Illumina WGS including 52/168 PE/PPE genes (34.5%). From these results, we present a refined list of low confidence regions across the Mtb genome, which we found to frequently overlap with regions with structural variation, low sequence uniqueness and low sequencing coverage. Our benchmarking results have broad implications for the use of WGS in the study of Mtb biology, inference of transmission in public health surveillance systems and more generally for WGS applications in other organisms.

AVAILABILITY AND IMPLEMENTATION

All relevant code is available at https://github.com/farhat-lab/mtb-illumina-wgs-evaluation.

SUPPLEMENTARY INFORMATION

Supplementary data are available at Bioinformatics online.

A Case of Gastric Outlet Obstruction Secondary to Parastomal Stomach Herniation

Parastomal hernia (PH) is an abnormal herniation of tissue or intra-abdominal organ through the fascial defect created at the ostomy site. It is a common complication of stoma creation and usually contains bowel, intra-abdominal fat, or omentum. Herniation of a fixed organ like the stomach is very rare and can lead to significant morbidity and mortality. Here, we present a case of an 83-year-old female with a history of sigmoidectomy and subsequent development of parastomal hernia who presented with abdominal pain, nausea, and vomiting and was found to have stomach herniation into the parastomal hernia sac. She was managed conservatively with intravenous (IV) fluids, electrolyte replacement, and decompression with a nasogastric (NG) tube. In this article, we have discussed the incidence, clinical presentation, diagnosis, and management of gastric involvement in the parastomal hernia that can help clinicians identify and treat it early at the time of presentation.

179 Using QIP to Create a Structured Teaching Programme to Improve Confidence in Basic Surgical Topics in Foundation Year 1 Doctors

Aim

We aim to create a new, structured teaching programme to help fill in knowledge gaps in newly qualified doctors, who have rotated into General Surgery.

Method

We ran the programme over three four-month periods.

Prior to each rotation, we used a survey to assess multiple aspects: prior experience of surgical teaching, overall feeling of preparedness and confidence. We also asked for a self-evaluation on the doctor's confidence for specific basic surgical topics, on a 5-point scale. We asked for suggestion topics that doctors found difficult or lacked confidence in. We used this information to create a curriculum for the programme.

We then reassessed these variables at the end of the cycle, using the information to plan and implement the next cycle.

Results

During the first cycle, we made no significant difference in any area. Experiencing significant barriers to attendance, organisation, and interaction with the survey. We used this first cycle to identify these barriers and address them for the second cycle.

These changes led to a significant improvement in attendance, feedback from sessions and interaction with the questionnaires. We saw a 3-fold increase in attendance to sessions on average.

After the second cycle, there was an overall improvement of confidence in all basic surgical topics. There was an increase in the number of doctors considering a career in surgery.

Conclusions

This teaching programme has led to an improvement in junior doctors’ confidence in basic surgical topics. Repeated PDSA cycles are allowing continuous improvement and change to maximise exposure to surgical teaching and training.

Comparison of scattered entrance skin dose burden in MSCT, CBCT, and X-ray for suspected scaphoid injury: Regional dose measurements in a phantom model

INTRODUCTION

Scaphoid radiography has poor sensitivity for acute fracture detection and often requires repeat delayed imaging. Although magnetic resonance (MR) imaging is considered the gold standard, computed tomography (CT) is often used as an alternative due to ease of access. Cone-Beam CT (CBCT) offers equivalent diagnostic efficacy to Multi Slice CT (MSCT) at reduced dose. We aimed to establish the difference in scattered dose between modalities for scaphoid imaging.

METHODS

Anatomical regional entrance surface dose measurements were taken at 3 regions on an anthropomorphic torso phantom positioned as a patient to a wrist phantom undergoing scaphoid imaging for three modalities (CBCT, MSCT, four-view projection radiography). Exposure factors were based on audit of clinical exposures. Each dose measurement was repeated three times per anatomical region, modality, exposure setting and projection.

RESULTS

Under unpaired T-test CBCT gave significantly lower mean dose at the neck (1.64 vs 18 mGy), chest (2.78 vs 8.01) and abdomen (1.288 vs 2.93) than MSCT (p < .0001). However CBCT had significantly higher mean dose than four-view radiography at the neck, chest and abdomen (0.031, 0.035, and 0.021 mGy) (p < .0001).

CONCLUSION

CBCT of the wrist carries a significantly higher scattered radiation dose to the neck, chest and abdomen than four view scaphoid radiography, but significantly lower scattered dose than MSCT of the wrist of equivalent diagnostic value.

IMPLICATIONS FOR PRACTICE

The use of CBCT for scaphoid injury carries significantly lower scattered dose to radio-sensitive structures investigated here than equivalent MSCT, and may be of greater use as an early cross-sectional investigation for suspected scaphoid fracture.

Hepatic FoxOs link insulin signaling with plasma lipoprotein metabolism through an apolipoprotein M/sphingosine-1-phosphate pathway

Multiple beneficial cardiovascular effects of HDL depend on sphingosine-1-phosphate (S1P). S1P associates with HDL by binding to apolipoprotein M (ApoM). Insulin resistance is a major driver of dyslipidemia and cardiovascular risk. However, the mechanisms linking alterations in insulin signaling with plasma lipoprotein metabolism are incompletely understood. The insulin-repressible FoxO transcription factors mediate key effects of hepatic insulin action on glucose and lipoprotein metabolism. This work tested whether hepatic insulin signaling regulates HDL-S1P and aimed to identify the underlying molecular mechanisms. We report that insulin-resistant, nondiabetic individuals had decreased HDL-S1P levels, but no change in total plasma S1P. This also occurred in insulin-resistant db/db mice, which had low ApoM and a specific reduction of S1P in the HDL fraction, with no change in total plasma S1P levels. Using mice lacking hepatic FoxOs (L-FoxO1,3,4), we found that hepatic FoxOs were required for ApoM expression. Total plasma S1P levels were similar to those in controls, but S1P was nearly absent from HDL and was instead increased in the lipoprotein-depleted plasma fraction. This phenotype was restored to normal by rescuing ApoM in L-FoxO1,3,4 mice. Our findings show that insulin resistance in humans and mice is associated with decreased HDL-associated S1P. Our study shows that hepatic FoxO transcription factors are regulators of the ApoM/S1P pathway.