Microsurgical limb reconstruction in the non-concordant patient

Substance misuse is common in patients undergoing limb reconstruction secondary to open fractures and fracture related infection. This group risk breaching the social contract with their treating team through reduced engagement with perioperative care. Potential problems include limited social support, intravenous access, analgesia and withdrawal. These factors may negatively influence the range of treatments offered to this group. We aimed to establish the prevalence and outcomes of the problematically non-concordant cohort in our limb reconstruction population, who we aim to treat equitably even where non-concordance is suspected pre-operatively. A retrospective study was performed using our prospectively collected free flap limb reconstruction database from December 2021-October 2023. Patient electronic health records were reviewed for demographics, perioperative details and outcomes. Eighty patients were identified, with 8 identified as problematically non-concordant (10%). All patients had a background of substance abuse; smoking (100%), alcohol (75%), IVDU (63%). Pre-operative non-concordance included absconding (43%), staff abuse (57%) and refusal of care (57%). Post-operative non-concordance included smoking (75%), mobilisation against instructions (75%), absconding (63%). No patients had free flap failure. Inpatient stay varied from 8-83 days, average 28.50% of patients did not attend follow-up. The expanding horizon of microsurgery means complex reconstruction is offered to a greater range of patients. Surgical teams should ensure that this service is offered equitably, individualising treatment plans to achieve the best outcomes. Risk of non-concordance is usually evident pre-operatively. We advise early involvement of substance misuse teams, discharge support and an understanding team to achieve good outcomes.

Sex-Specific Effect of MTSS1 Downregulation on Dilated Cardiomyopathy

MTSS1 (metastasis suppressor 1) is an I-BAR protein that regulates cytoskeleton dynamics through interactions with actin, Rac, and actin-associated proteins. In a prior study, we identified genetic variants in a cardiac-specific enhancer upstream of MTSS1 that reduce human left ventricular (LV) MTSS1 expression and associate with protection against dilated cardiomyopathy (DCM). We sought to probe these effects further using population genomics and in vivo murine models. We crossed Mtss1 -/- mice with a transgenic ( Tg ) murine model of human DCM caused by the D230N pathogenic mutation in Tpm1 (tropomyosin 1). In females, Tg/Mtss1 +/- mice had significantly increased LV ejection fraction and reduced LV volumes relative to their Tg/Mtss1 +/+ counterparts, signifying partial rescue of DCM due to Mtss1 haploinsufficiency. No differences were observed in males. To study effects in humans, we fine-mapped the MTSS1 locus with 82 cardiac magnetic resonance (CMR) traits in 22,381 UK Biobank participants. MTSS1 enhancer variants showed interaction with biological sex in their associations with several CMR traits. After stratification by biological sex, associations with CMR traits and colocalization with MTSS1 expression in the Genotype-Tissue Expression (GTEx) Project were observed principally in women and were substantially weaker in men. These findings suggest sex dimorphism in the effects of MTSS1-lowering alleles, and parallel the increased LV ejection fraction and reduced LV volumes observed female Tg/Mtss1 +/- mice. Together, our findings at the MTSS1 locus suggest a genetic basis for sex dimorphism in cardiac remodeling and motivate sex-specific study of common variants associated with cardiac traits and disease.

Leisure-time and competitive sport participation: a changing paradigm for HCM patients

HCM has long been considered the most frequent cause of death in athletes, and reason for disqualification from sport. However, our perception of the impact of sports on HCM is largely based on anecdotal evidence. In this review, we provide a reappraisal of current knowledge relative to 1) the impact of sport on LV remodeling, and 2) on the clinical outcome of HCM in athletes. 1) The limited available evidence argues against the hypothesis that intensive exercise conditioning may trigger and/or worsen the development of LV hypertrophy or cause changes in LV function in adult HCM athletes. 2) Recent observations challenge the concept of a detrimental effect of sport on HCM clinical course. The Reset-HCM study showed that 16-week moderate-intensity exercise resulted in a small, significant increase in exercise capacity and no adverse events. In a cohort of 88 low-risk HCM athletes followed for a 7-year period, survival analyses showed no difference in mortality between HCM who discontinued or pursued vigorous exercise programmes. Further reassurance was provided by the ICD Sports Safety Registry. Clinical implications: At present, patients' attitude to sport participation is highly variable, based on social and legal backgrounds surrounding medical practice in different countries. The shared-decision-making as suggested by current US and European guidelines allows the physician to deliver a tailored and more liberal advice. Physicians should be aware of the changing paradigm relative to exercise and sport prescription for HCM and promote active lifestyle as an integral component of modern management of HCM patients.

Outcome Measures Used to Assess Hand Activity in Amputee and Intact Populations: a Literature Review

BACKGROUND

The human hand is critical in assisting with activities of daily living (ADL). Amputation of the hand can affect a person physically, socially and psychologically. Knowledge of outcome measures used to assess upper limb activity of intact and amputee populations may aid in guiding research to develop applicable measurement tools specific to the amputee population. Tools could aid developments in prosthetic design and prescription, which benefit both users and healthcare researchers.

OBJECTIVES

This literature review examined outcome measurement tools used with non-amputee and amputee populations to assess hand activity. The objectives were to identify which characteristics of hand activity are captured by currently available measurement tools.

METHODOLOGY

Searches were conducted using PubMed, Cochrane and ProQuest for studies investigating hand activity for amputee and non-amputee populations. A total of 15 studies were included. PRISMA guidelines were used to assist with study selection. Data extraction and narrative synthesis were carried out.

FINDINGS

A total of 32 outcome measures were found. Frequently used tools were: Box and Block Test, Swedish Disabilities of the Arm Shoulder and Hand Questionnaire, and range of motion. Studies employed a combination of 2 to 12 tools. Themes extracted were: importance of function and quality of life, the need for realistic tasks, and the need for outcome measures specific of the population.

CONCLUSION

There is a gap in research surrounding outcome measurement tools used to assess hand activity in the amputee population. A combination of outcome measures are required to obtain insight into the hand activities of intact and amputee populations. Function and quality of life are important aspects to consider when describing hand activity.

Does Trans-radial Longitudinal Compression Influence Myoelectric Control?

BACKGROUND

Existing trans-radial prosthetic socket designs are not optimised to facilitate reliable myoelectric control. Many socket designs pre-date the introduction of myoelectric devices. However, socket designs featuring improved biomechanical stability, notably longitudinal compression sockets, have emerged in more recent years. Neither the subsequent effects, if any, of stabilising the limb on myoelectric control nor in which arrangement to apply the compression have been reported.

METHODOLOGY

Twelve able-bodied participants completed two tasks whilst wearing a longitudinal compression socket simulator in three different configurations: 1) compressed, where the compression strut was placed on top of the muscle of interest, 2) relief, where the compression struts were placed either side of the muscle being recorded and 3) uncompressed, with no external compression. The tasks were 1) a single-channel myoelectric target tracking exercise, followed by 2), a high-intensity grasping task. The wearers' accuracy during the tracking task, the pressure at opposing sides of the simulator during contractions and the rate at which the limb fatigued were observed.

FINDINGS

No significant difference between the tracking-task accuracy scores or rate of fatigue was observed for the different compression configurations. Pressure recordings from the compressed configuration showed that pressure was maintained at opposing sides of the simulator during muscle contractions.

CONCLUSION

Longitudinal compression does not inhibit single-channel EMG control, nor improve fatigue performance. Longitudinal compression sockets have the potential to improve the reliability of multi-channel EMG control due to the maintenance of pressure during muscle contractions.

Worldwide differences in primary prevention implantable cardioverter defibrillator utilization and outcomes in hypertrophic cardiomyopathy

AIMS

Risk stratification algorithms for sudden cardiac death (SCD) in hypertrophic cardiomyopathy (HCM) and regional differences in clinical practice have evolved over time. We sought to compare primary prevention implantable cardioverter defibrillator (ICD) implantation rates and associated clinical outcomes in US vs. non-US tertiary HCM centres within the international Sarcomeric Human Cardiomyopathy Registry.

METHODS AND RESULTS

We included patients with HCM enrolled from eight US sites (n = 2650) and five non-US (n = 2660) sites and used multivariable Cox-proportional hazards models to compare outcomes between sites. Primary prevention ICD implantation rates in US sites were two-fold higher than non-US sites (hazard ratio (HR) 2.27 [1.89-2.74]), including in individuals deemed at high 5-year SCD risk (≥6%) based on the HCM risk-SCD score (HR 3.27 [1.76-6.05]). US ICD recipients also had fewer traditional SCD risk factors. Among ICD recipients, rates of appropriate ICD therapy were significantly lower in US vs. non-US sites (HR 0.52 [0.28-0.97]). No significant difference was identified in the incidence of SCD/resuscitated cardiac arrest among non-recipients of ICDs in US vs. non-US sites (HR 1.21 [0.74-1.97]).

CONCLUSION

Primary prevention ICDs are implanted more frequently in patients with HCM in US vs. non-US sites across the spectrum of SCD risk. There was a lower rate of appropriate ICD therapy in US sites, consistent with a lower-risk population, and no significant difference in SCD in US vs. non-US patients who did not receive an ICD. Further studies are needed to understand what drives malignant arrhythmias, optimize ICD allocation, and examine the impact of different ICD utilization strategies on long-term outcomes in HCM.

BSHI/BTS guidance on crossmatching before deceased donor kidney transplantation

All UK H&I laboratories and transplant units operate under a single national kidney offering policy, but there have been variations in approach regarding when to undertake the pre‐transplant crossmatch test. In order to minimize cold ischaemia times for deceased donor kidney transplantation we sought to find ways to be able to report a crossmatch result as early as possible in the donation process. A panel of experts in transplant surgery, nephrology, specialist nursing in organ donation and H&I (all relevant UK laboratories represented) assessed evidence and opinion concerning five factors that relate to the effectiveness of the crossmatch process, as follows: when the result should be ready for reporting; what level of donor HLA typing is needed; crossmatch sample type and availability; fairness and equity; risks and patient safety. Guidelines aimed at improving practice based on these issues are presented, and we expect that following these will allow H&I laboratories to contribute to reducing CIT in deceased donor kidney transplantation.

Abstract P511: Sirtuin 5 Overexpression Protects Against Pressure Overload-Induced Ventricular Dysfunction

Heart failure (HF) is defined as an inability of the heart to pump blood sufficiently to meet the metabolic demands of the body. HF with systolic dysfunction is caused by a progressive decline in contractile function and chronic hemodynamic overload, and characterized by ventricular hypertrophy and remodeling, neurohormonal compensation mechanisms, and myocardial damage. Transverse aortic constriction (TAC) is a well-established model for inducing hypertrophy and HF in rodents. Mice globally deficient in sirtuin 5 (SIRT5), a NAD + -dependent deacylase, are hypersensitive to cardiac stress and display increased mortality after TAC. Prior studies assessing SIRT5 functions in the heart have all employed loss-of-function approaches. In this study, we generated SIRT5 overexpressing (SIRT5OE) mice, and evaluated their response to chronic pressure overload using TAC. Compared to littermate controls, elevated SIRT5 levels promoted maintenance of cardiac contractile function after 4 weeks of pressure overload, at which point control mice had developed systolic dysfunction, characterized by decreased EF, coupled with ventricular dilation, remodeling and fibrosis. Transcriptomic analysis revealed that SIRT5 suppresses key HF sequelae, including metabolic switch from fatty acid oxidation to glycolysis and immune activation ( i.e., TGFβ, IL6, Renin-Angiotensin, and NFAT, and fibrotic signaling pathways). We conclude that SIRT5 is a limiting factor in the preservation of cardiac function in response to experimental pressure overload.

P90 PERCEIVE: PrEdiction of Risk and Communication of outcome following major lower limb amputation - a collaboratIVE study

Introduction

Major Lower Limb Amputation (MLLA) is a life changing event with significant morbidity and mortality. Inaccurate risk prediction can lead to poor decision making, resulting in delay to definitive surgery, or undertaking amputation when not in the patient’s best interest. We aim to answer: In adult patients undergoing MLLA for chronic limb threatening ischaemia or diabetes, how accurately do health care professionals prospectively predict outcomes after MLLA, and how does this compare to existing prediction tools?

Methods

A multicentre prospective observational cohort study is being delivered through the Vascular and Endovascular Research Network. Dissemination was via an existing network of contacts and social media.

Consecutive data will be collected for seven months from site launch date, including demographic data and pre-operative outcome predictions from surgeons, anaesthetists, and allied healthcare professionals. Follow-up data will comprise 30-day (mortality, morbidity, MLLA revision, surgical site infection, and blood transfusion) and 1-year (mortality, MLLA revision and ambulation). The accuracy of surgeons’ predictions will be evaluated and compared to pre-existing risk prediction scoring tools.

Results

PERCEIVE launched on 01/10/2020 with 23 centres (16 UK, 7 international) registered to collect data. 50 other centres (27 UK, 23 international) have expressed interest/are pursuing local audit/ethical approval. We aim to collect data on clinicians estimate of outcomes for over 500 patients.

Discussion

This study will utilise a trainee research network to provide data on the accuracy of healthcare professionals’ predictions of outcomes following MLLA and compare this to the utility of existing prediction tools in this patient cohort.

Determinants of lost theatre capacity

Secondary care Trusts nationwide are continuing to fail the 18-week referral to treatment (RTT) target despite several initiatives to improve theatre efficiency (2018 NHS England review). A limitation of wasted theatre productivity is required to alleviate pressures on waiting lists. Productivity, which is a measure of treatment time as a proportion of available/allocated time, takes into consideration variations in operator performance, early (non-funded) theatre starts, and over-run, and its analysis enables the determination of theatre downtime and lost theatre capacity. We monitored productivity over a 12-week period and performed downtime analysis as reported in the NHS Improvement national audit (NHSI). Results showed a marked but predictable variation in productivity connected to turnaround and session list scheduling. Productivity and booking efficiency correlated uniformly (Pearson's r=0.82). Theatre downtime was analysed with respect to three components defined in the NHSI national audit: late starts, early finish, and turnaround. We found that lost theatre time was predominantly due to early finishes; late starts were infrequent. Transport time correlated unfavourably with productivity (Pearson's r=-0.29, p=0.037) and over-run (r=0.44), and prolonged transport times were shorter when surgery was performed in a dedicated day surgery unit. Calculating the mean transport times for lists with high compared with low productivity helped us set a benchmark for patient transport times for future audit.

Psychological intervention (ConquerFear) for treating fear of cancer recurrence: mediators and moderators of treatment efficacy

PURPOSE

ConquerFear is an efficacious intervention for fear of cancer recurrence (FCR) that demonstrated greater improvements than an attention control (relaxation training) in a randomized controlled trial. This study aimed to determine mediators and moderators of the relative treatment efficacy of ConquerFear versus relaxation.

METHODS

One hundred and fifty-two cancer survivors completed 5 therapy sessions and outcome measures before and after intervention and at 6 months' follow-up. We examined theoretically relevant variables as potential mediators and moderators of treatment outcome. We hypothesized that metacognitions and intrusions would moderate and mediate the relationship between treatment group and FCR level at follow-up.

RESULTS

Only total FCR score at baseline moderated treatment outcome. Participants with higher levels of FCR benefited more from ConquerFear relative to relaxation on the primary outcome. Changes in metacognitions and intrusive thoughts about cancer during treatment partially mediated the relationship between treatment group and FCR.

CONCLUSIONS

These results show that ConquerFear is relatively more effective than relaxation for those with overall higher levels of FCR. The mediation analyses confirmed that the most likely mechanism of treatment efficacy was the reduction in unhelpful metacognitions and intrusive thoughts during treatment, consistent with the theoretical framework underpinning ConquerFear.

IMPLICATIONS FOR CANCER SURVIVORS

ConquerFear is a brief, effective treatment for FCR in cancer survivors with early-stage disease. The treatment works by reducing intrusive thoughts about cancer and changing beliefs about worry and is particularly helpful for people with moderate to severe FCR.

Murine thrombosis models

Due to exciting advances in molecular biology, the laboratory mouse has become an important and frequently used model for studying thrombosis. This article reviews several experimental approaches that have been used to study arterial, venous, and microvascular thrombosis in mice. The advantages and limitations of different models are examined. Related topics of mouse anesthesia, phlebotomy, and in vitro hemostasis testing are also reviewed.

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.

Abstract 385: Cardiac Myosin Binding Protein-C Mutants Disrupt Ubiquitin Proteasome System and Hsc70 Functions

The most commonly mutated gene in hypertrophic cardiomyopathy (HCM) is cardiac myosin binding protein C (MYBPC3). Over 90% of MYBPC3 mutations are nonsense, but whether these mutations manifest in loss- or gain-of-function is unresolved. Evidence suggests MYBPC3 mutants impact protein quality control mechanisms. The objective of this study was to evaluate interactions of MYBPC3 with proteostatic systems and test the hypothesis that these interactions affect protein homeostasis in cardiomyocytes.

WT and mutant MYBPC3 constructs were expressed in neonatal rat ventricular myocytes (NRVMs) via adenovirus. Mutant MYBPC3 induced ubiquitin proteasome system reporter GFPu accumulation (fold increase in GFPu-positive cells vs control: WT 138±14.0%, mutant 198±27.2%, mean±SEM, p<0.05 vs control and WT), indicating proteasome dysfunction. Affinity purification/mass spectrometry identified molecular chaperones Hsp70 and Hsc70 as prominent interactors with MYBPC3. We observed MYBPC3 degradation by cycloheximide chase in response to Hsc70 siRNA knockdown or pharmacological treatment with Hsp70 activator YM-1. Hsc70 knockdown slowed degradation of WT and mutant MYBPC3 (WT control t ½ =5.47±0.70 hr, WT Hsc70 knockdown t ½ =13.5±1.62 hr; mutant control t ½ =3.42±0.61 hr, mutant Hsc70 knockdown t ½ =9.87±0.95 hr), while YM-1 treatment accelerated degradation (WT DMSO t ½ =10.2±3.28 hr, WT YM-1 t ½ =3.16±0.61 hr; mutant DMSO t ½ =11.7±2.67 hr, mutant YM-1 t ½ =1.37±0.16 hr). We then evaluated whether transferrin uptake via clathrin mediated endocytosis, a critical Hsc70-dependent activity, was affected by mutant MYBPC3. Transferrin uptake was significantly decreased in NRVMs expressing mutant MYBPC3 compared to WT and untreated controls (transferrin-positive cells: control 22.93±3.34%, WT 17.47±0.70%, mutant 9.30±1.63%, mean±SEM, p<0.05 vs control and WT).

In conclusion, we have demonstrated that Hsp70 chaperones interact with MYBPC3 in cardiomyocytes and affect MYBPC3 degradation, suggesting MYBPC3 is a client of Hsp70 and Hsc70. Additionally, expression of mutant MYBPC3 causes ubiquitin proteasome impairment and interferes with normal Hsc70 function. These results support our hypothesis that mutant MYBPC3 affects protein homeostasis in HCM.

Geochemical and mineralogical characterization of sulfur and iron in coal waste rock, Elk Valley, British Columbia, Canada

Exposure of coal waste rock to atmospheric oxygen can result in the oxidation of sulfide minerals and the release of sulfate (SO₄^2-) and associated trace elements (e.g., Se, As, Cd, and Zn) to groundwaters and surface waters. Similarly, reduced iron minerals such as siderite, ankerite, and the sulfide, pyrite, present in the waste rock can also undergo oxidation, resulting in the formation of iron oxyhydroxides that can adsorb trace elements released from the oxidation of the sulfide minerals. Characterization and quantification of the distribution of sulfide and iron minerals, their oxidation products, as well as leaching rates are critical to assessing present-day and future impacts of SO₄^2- and associated trace elements on receiving waters. Synchrotron-based X-ray absorption near edge spectroscopic analysis of coal waste rock samples from the Elk Valley, British Columbia showed Fe present as pyrite (mean 6.0%), siderite (mean 44.3%), goethite (mean 35.4%), and lepidocrocite (mean 14.3%) with S present as sulfide (mean 26.9%), organic S (mean 58.7%), and SO₄^2- (mean 14.4%). Squeezed porewater samples from dump solids yielded mean concentrations of 0.28mg/L Fe and 1246mg/L SO₄^2-. Geochemical modeling showed the porewaters in the dumps to be supersaturated with respect to Fe oxyhydroxides and undersaturated with respect to gypsum, consistent with solids analyses. Coupling Fe and S mineralogical data with long-term water quality and quantity measurements from the base of one dump suggest about 10% of the sulfides (which represent 2% of total S) in the dump were oxidized over the past 30years. The S from these oxidized sulfides was released to the receiving surface water as SO₄^2- and the majority of the Fe precipitated as secondary Fe oxyhydroxides (only 3.0×10^-5% of the Fe was released to the receiving waters over the past 30years). Although the data suggest that the leaching of SO₄^2- from the waste rock dump could continue for about 300years, assuming no change in the rate of oxidation of sulfides, SO₄^2- is currently not a concern in receiving surface waters as the concentration levels are below regulatory limits.

Retrospective review of the management of epididymo-orchitis in a London-based level 3 sexual health clinic: an audit of clinical practice

The aetiology of epididymo-orchitis is largely related to a patient's age with sexually transmitted pathogens being the common aetiological agents in those below 35 years of age. In individuals aged over 35, uropathogens represent the commonest cause. National guidelines exist for the appropriate management of this condition and its varying aetiology. We aimed to assess the management of epididymo-orchitis in our clinic with reference to the British Association for Sexual Health and HIV national guidelines. We describe the demographics, investigations, treatment and outcomes of patients presenting with epididymo-orchitis to the John Hunter Clinic for Sexual Health, Chelsea and Westminster Hospital.

Cardiac Myosin Binding Protein-C Autoantibodies are Potential Early Indicators of Cardiac Dysfunction and Patient Outcome in Acute Coronary Syndrome

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ACS remains a leading cause of death worldwide.

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cMyBP-C-AAbs were detected in ACS patients' sera upon arrival to the emergency department.

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The presence of cMyBP-C-AAbs was negatively associated with cardiovascular function and positively associated with the degree of myocardial injury as determined by circulating levels of serum proteins in ACS patients.

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The development of novel indicators to predict infarction severity and cardiovascular function following ischemic injury may provide early treatment recommendations for ACS patients to limit myocardial damage.

The degradation and release of cardiac myosin binding protein-C (cMyBP-C) upon cardiac damage may stimulate an inflammatory response and autoantibody (AAb) production. We determined whether the presence of cMyBP-C-AAbs associated with adverse cardiac function in cardiovascular disease patients. Importantly, cMyBP-C-AAbs were significantly detected in acute coronary syndrome patient sera upon arrival to the emergency department, particularly in ST-segment elevation myocardial infarction patients. Patients positive for cMyBP-C-AAbs had reduced left ventricular ejection fraction and elevated levels of clinical biomarkers of myocardial infarction. We conclude that cMyBP-C-AAbs may serve as early predictive indicators of deteriorating cardiac function and patient outcome in acute coronary syndrome patients prior to the infarction.

Mondor's disease of the penis following a long-haul flight

Mondor's disease of the penis, otherwise known as superficial thrombophlebitis (STP) or thrombosis of the dorsal vein, is an under-reported benign condition, the aetiology of which is poorly understood. It is characterized by a sudden, indurated swelling of the vein, often occurring after vigorous sexual activity. We report a case of Mondor's disease occurring 24h following a 15h flight. This gentleman also reported a history of STP of his left lower limb varicose veins following a similar-length flight three years previously. In the absence of any other clear predisposing factor, we propose long-haul flight as an important factor contributing to the development of dorsal vein thrombosis.

Maids, Migrants and Occupational Health in the London Sex Industry

It has been argued that norms of occupational health have weakened with diversification in the sex industry. We explore this issue in walk-in flats in London, focusing on relationships between managers (maids) and sex workers. Today, most maids are local and most sex workers are 'migrants'. We collected data on 117 maids and sex workers, and carried out intensive fieldwork with seven maids and 17 sex workers. Managers take prime responsibility for educating and inducting new workers. Authoritarian management has been considered bad for health both in these walk-in flats and in the '100 per cent condom use programme' criticized by sex workers' projects. Yet, we found that maids acted as friends and managers, which helped settle new sex workers. Over time, however, migrants were more affected by issues of isolation and exploitation than local workers. Alternative models of health promotion such as peer education must be seen in a wider legal context where the lack of rights makes it difficult to appeal against exploitation, or to become mobile.

Abstract 343: Bayesian Selection of Modifier Genes in Hypertrophic Cardiomyopathy Through Whole Genome Sequencing

Background: Technological advances have greatly reduced the cost of whole genome sequencing. For single individuals clinical application is apparent, while exome sequencing in tens of thousands of people has allowed a more global view of genetic variation that can inform interpretation of specific variants in individuals. We hypothesized that genome sequencing of patients with monogenic cardiomyopathy would facilitate discovery of genetic modifiers of phenotype.

Methods and Results: We identified 48 individuals diagnosed with cardiomyopathy and with putative mutations in MYH7, the gene encoding beta myosin heavy chain. We carried out whole genome sequencing and applied a newly developed analytical pipeline optimized for discovery of genes modifying severity of clinical presentation and outcomes. Using a combination of external priors and rare variant burden tests we scored genes as potential modifiers. There were 96 genes that reached a modifier score of 6 out of 12 or better (9=2, 8=8, 7=17, 6=69). We identified NCKAP1, a gene that regulates actin filament dynamics, and CAMSAP1, a calmodulin regulate gene that regulates microtubule dynamics, as top scoring modifiers of hypertrophic cardiomyopathy phenotypes (score=9) while LDB2, RYR2, FBN1 and ATP1A2 had modifier scores of 8. Of the top scoring genes, 21 out of 96 were identified as candidates a priori. Our candidate prioritization scheme identified the previously described modifiers of cardiomyopathy phenotype, FHOD3 and MYBPC3, as top scoring genes. We identified structural variants in 21 clinically sequenced cardiomyopathy associated genes, 13 of which were at less than 10% frequency. Copy number variants in ILK and CSRP3 were nominally associated with ejection fraction (p=0.03), while 8 genes showed copy gains (GLA, FKTN, SGCD, TTN, SOS1, ANKRD1, VCL and NEBL). Structural variants were found in CSRP3, MYL3 and TNNC1, all of which have been implicated as causative for HCM.

Conclusion: Evaluation of the whole genome sequence, even in the case of putatively monogenic disease, leads to important diagnostic and scientific insights not revealed by panel-based sequencing.

The effects of cancer research participation on patient experience: a mixed-methods analysis

Patient-reported benefits of research participation have been described by study participants; however, many studies have small sample sizes or are limited to patient groups with poor prognoses. The purpose of this study was to explore the effects of research participation on patient experience using survey responses from a large, national sample of cancer patients (N = 66 462) and interviews with breast cancer patients attending a London trust. Multivariate logistic regression was used to investigate associations between taking part in research and positive patient experience. Based on our analysis, patients who participated in research were more likely to rate their overall care and treatment as 'very good/excellent' (OR_adj :1.64, 95%CI: 1.53-1.76, P < 0.001) and to describe positive patient experiences, such as better access to non-standard care, better interactions with staff and being treated as an individual. However, findings from our interviews indicated that there was no common understanding of what constitutes cancer research and no clear delineation between research participation and standard care, from the patient perspective. Further work to explore how participation positively influences patient experience would be useful to develop strategies to improve care and treatment for all patients regardless of whether or not they choose, or have the opportunity, to take part in research.

Clinical phenotype and outcome of hypertrophic cardiomyopathy associated with thin-filament gene mutations

Background

Mild hypertrophy but increased arrhythmic risk characterizes the stereotypic phenotype proposed for hypertrophic cardiomyopathy (HCM) caused by thin-filament mutations. However, whether such clinical profile is different from more prevalent thick-filament–associated disease is unresolved.

Objectives

This study aimed to assess clinical features and outcomes in a large cohort of patients with HCM associated with thin-filament mutations compared with thick-filament HCM.

Methods

Adult HCM patients (age >18 years), 80 with thin-filament and 150 with thick-filament mutations, were followed for an average of 4.5 years.

Results

Compared with thick-filament HCM, patients with thin-filament mutations showed: 1) milder and atypically distributed left ventricular (LV) hypertrophy (maximal wall thickness 18 ± 5 mm vs. 24 ± 6 mm; p < 0.001) and less prevalent outflow tract obstruction (19% vs. 34%; p = 0.015); 2) higher rate of progression to New York Heart Association functional class III or IV (15% vs. 5%; p = 0.013); 3) higher prevalence of systolic dysfunction or restrictive LV filling at last evaluation (20% vs. 9%; p = 0.038); 4) 2.4-fold increase in prevalence of triphasic LV filling pattern (26% vs. 11%; p = 0.002); and 5) similar rates of malignant ventricular arrhythmias and sudden cardiac death (p = 0.593).

Conclusions

In adult HCM patients, thin-filament mutations are associated with increased likelihood of advanced LV dysfunction and heart failure compared with thick-filament disease, whereas arrhythmic risk in both subsets is comparable. Triphasic LV filling is particularly common in thin-filament HCM, reflecting profound diastolic dysfunction.

Maca reduces blood pressure and depression, in a pilot study in postmenopausal women

OBJECTIVE

Lepidium meyenii (Maca) has been used for centuries for its fertility-enhancing and aphrodisiac properties. In an Australian study, Maca improved anxiety and depressive scores. The effects of Maca on hormones, lipids, glucose, serum cytokines, blood pressure, menopausal symptoms and general well-being in Chinese postmenopausal women were evaluated.

METHODS

A randomized, double-blind, placebo-controlled, cross-over study was conducted in 29 postmenopausal Hong Kong Chinese women. They received 3.3 g/day of Maca or placebo for 6 weeks each, in either order, over 12 weeks. At baseline, week 6 and week 12, estradiol, follicle stimulating hormone (FSH), sex hormone binding globulin (SHBG), thyroid stimulating hormone (TSH), full lipid profiles, glucose and serum cytokines were measured. The Greene Climacteric, SF-36 Version 2, Women's Health Questionnaire and Utian Quality of Life Scales were used to assess the severity of menopausal symptoms and health-related quality of life.

RESULTS

There were no differences in estradiol, FSH, TSH, SHBG, glucose, lipid profiles and serum cytokines amongst those who received Maca as compared to the placebo group; however, significant decreases in diastolic blood pressure and depression were apparent after Maca treatment.

CONCLUSIONS

Maca did not exert hormonal or immune biological action in the small cohort of patients studied; however, it appeared to reduce symptoms of depression and improve diastolic blood pressure in Chinese postmenopausal women. Although results are comparable to previous similar published studies in postmenopausal women, there might be a cultural difference among the Chinese postmenopausal women in terms of symptom reporting.

Abstract 236: Obstructive Sleep Apnea in Hypertrophic Cardiomyopathy: Comparing Exercise Tolerance, Cardiac Remodeling, Clinical and Genetic Data

Background: Prevalence of obstructive sleep apnea (OSA) in hypertrophic cardiomyopathy (HCM) is estimated between 32% and 71%. Individuals with HCM and OSA have increased blood pressure, BMI, , ascending aorta size, left atrial size, left ventricular end diastolic diameter, E/e’ ratio, atrial fibrillation rates and NYHA functional class. It has been suggested that treatment of OSA can decrease the need for septal reduction. However, studies have found no effect of OSA on septal thickness or outflow gradient. It is not known how OSA affects exercise performance or cardiac remodeling assessed by MR. Genetic propensity toward OSA in HCM has not been reported. We propose that OSA predicts decrease exercise tolerance and that cardiac remodeling could be identified using MR. We sought to report on HCM genotype in OSA as well as compare our clinical and echo data with other investigators.

Methods: Subjects were identified through our institution’s HCM database. They were surveyed using the STOP-BANG (SB) questionnaire, a validated questionnaire to identify individuals at high risk for OSA. We stratified patients into high risk (HR) and low risk (LR) groups, based on a cut point of greater than or equal to 3 on SB. Demographics and clinical characteristics were extracted from our database. Prevalence and means were compared between the two groups, using Chi-square and t-tests. Differences between the groups were adjusted for age, sex, and BMI using linear mixed models for continuous measures and logistic regression for dichotomous measures.

Results: There were 206 respondents, of those 160 (78%) scored high risk for OSA, 60 of which had a history of polysomnogram (PSG) confirming OSA. Having a HR vs. LR SB was associated with a significantly greater likelihood of stroke, CHF hospitalization, NYHA functional class >2, reduced peak VO2, reduced anaerobic threshold and increased LA diameter. Adjusted comparisons for age, gender, and BMI showed that had significantly higher PAWP and LV mass index. Of those with a prior diagnosis of OSA we compared therapy compliant and non-compliant individuals and found they differed on LV mass index (HR=98.7 g/m2 vs. LR=62.0 g/m2, p=0.01).

Conclusions: OSA occurs frequently in HCM and is associated with decreased exercise tolerance, worse hemodynamics, poor outcome as well as increased LV mass, which may be attenuated by therapy. OSA is an important and modifiable risk factor in HCM. Prospective evaluation utilizing PSG based diagnosis and positive pressure therapy is warranted.

Health of adults living with a clinically significant haemoglobinopathy in New South Wales, Australia

AIM

To comprehensively review the health needs of patients living with clinically significant haemoglobinopathies (thalassaemia and sickle-cell disease (SCD)) in New South Wales, Australia.

METHODS

A survey-based health needs assessment was undertaken in outpatients cared for at five tertiary institutions in metropolitan and regional centres. Sixty-three of 121 adults (approximately 80-90% of adult patients with transfusion-requiring haemoglobinopathies in New South Wales) completed an in-house and commercial health-related quality assessment survey (SF-36v2).

RESULTS

Subjects came from more than eight world regions, with those with SCD being more likely to be born outside of Australia than subjects with thalassaemia (P < 0.001, likelihood ratio 20.64) as well as more likely to have been refugees (26% vs 2%). The population contained socially disadvantaged subjects with 13 subjects (20.6%) having incomes below the Australian poverty line. Complications of thalassaemia were comparable to previous international reports although our subjects had a high rate of secondary amenorrhea (>12 months = 27%) and surgical splenectomy (55.6%). Use of hydroxyurea in SCD was less than expected with only 46.6% of subjects having prior use. Lack of universal access to magnetic resonance imaging-guided chelation (international best practice) was evident, although 65.5% had been able to access magnetic resonance imaging through clinical trial, or self-funding.

CONCLUSIONS

Patients with SCD and thalassaemia experience considerable morbidity and mortality and require complex, multidisciplinary care. This study revealed both variance from international best practice and between specialist units. The results of this research may provide the impetus for the development of clinical and research networks to enable the uniform delivery of health services benchmarked against international standards.

A retained menstrual cup

A 20-year-old woman attended a genitourinary clinic with a retained vaginal Mooncup that she had inserted the night before. A Mooncup is one type of menstrual cup. On speculum examination the device was visualized high in the vagina and the cervix appeared firmly lodged within it. The physician experienced difficulty in retrieving the cup despite following product instructions. This case highlights a new adverse event with an increasingly used sanitation product. It is important that clinicians are familiar with the cup, its removal process and are able to counsel patients with retained devices on future correct placement.