Assessing Pediatric Dental Resident Sedation Skills and Confidence with Simulation: A Pilot Study

Purpose: To conduct a pilot study assessing resident performance and self-efficacy during sedation-related simulations. Methods: Residents completed one informed consent and two sedation-related emergency simulations. Performance was measured for each simulation. Self- efficacy (i. e., confidence) was measured via pre- and post-simulation questionnaires. Descriptive and nonparametric statistics were calculated. Results: Twenty-five residents completed the simulations. Second-year residents performed better than first-year residents in both informed consent and emergency simulations; however, only the informed consent simulation was significant (P<0.02). Self-efficacy significantly increased after completing the simulations (18 percent pre-simulation versus 42.7 percent post-simulation, P<0.001). Residents identified communication skills as an area of improvement after the simulations. For the emergency vignettes, residents expressed feeling inadequate knowledge, problem-solving skills, and teamwork during the simulation. Conclusions: Simulations improved resident confidence in obtaining informed consent and managing certain sedation-related emergencies, but residents felt ill-prepared to manage an emergency. Further study is warranted to understand the best-practice frequency of sedation-related emergency simulation to promote skill retention.

Highlighting extended-spectrum beta-lactamase-producing Klebsiella pneumoniae outbreak by routine genomic typing

Whole genome sequencing has become the gold standard for any microbiological investigations. Taking the opportunity to doing it prospectively and routinely allowed to detect undeclared outbreaks. Thanks to that, we investigated and ended a rare epidemic extended-spectrum beta-lactamase-producing Klebsiella pneumoniae ST584 strain on two intensive care units over a 4-month period.

Creation of a Novel Child Simulator and Curriculum to Optimize Administration of Seizure Rescue Medication

INTRODUCTION

Although most cases of pediatric convulsive status epilepticus start in the prehospital setting, many patients do not receive treatment. The use of prehospital seizure rescue medications by caregivers is crucial, but studies suggest a lack of proper training on medication use.

METHODS

We created a novel proof of principle mannequin and simulation for training proper administration of rectal diazepam, with a scoring paradigm to standardize and assess the educational process.

RESULTS

Twenty-three health care providers (nurses and nurse practitioners, residents/fellows, and attending physicians) and 5 patient guardians/parents were included in the study. The rectal diazepam simulator displayed a high degree of physical and emotional realism (mean ≥ 4/5 on Likert scale survey) that effectively decreased time to treatment (-12.3 seconds; SD, 16.3) and improved the accuracy of medication delivery in a simulation setting (-4.2 points; SD, 3.1). The scoring technique had appropriate interrater reliability (≥86% on all but 2 prompts) and was a feasible instrument to assess the effectiveness of the educational intervention.

CONCLUSIONS

A unique procedure-focused child simulator and rescue medication score offer an innovative and effective means to train caregivers on the use of lifesaving seizure rescue medications.

Modulation of Radiation Biomarkers in a Randomized Phase II Study of 131I-MIBG With or Without Radiation Sensitizers for Relapsed or Refractory Neuroblastoma

PURPOSE

¹³¹I-metaiodobenzylguanidine (¹³¹I-MIBG) has demonstrated efficacy as a single agent in neuroblastoma. Recent trials have focused on ¹³¹I-MIBG combination strategies, though little is known about the effect of putative radiosensitizers on biological markers of radiation exposure.

METHODS AND MATERIALS

NANT2011-01 evaluated ¹³¹I-MIBG therapy alone (arm A) or in combination with vincristine/irinotecan (arm B) or vorinostat (arm C) for patients with relapsed or refractory neuroblastoma. Blood samples were collected before and after ¹³¹I-MIBG infusion to determine levels of radiation-associated biomarkers (transcript and protein). The association of biomarker with treatment arm, clinical response, and treatment toxicity was analyzed.

RESULTS

The cohort included 99 patients who had at least 1 biomarker available for analysis. Significant modulation in most biomarkers between baseline, 72, and 96 hours following ¹³¹I-MIBG was observed. Patients in arm C had the lowest degree of modulation in FLT3 ligand protein. Lower baseline BCL2 transcript levels were associated with higher overall response. Patients with greater increases in FLT3 ligand at 96 hours after ¹³¹I-MIBG therapy were significantly more likely to have grade 4 thrombocytopenia. Peripheral blood gene expression of the BCL2 family of apoptotic markers (BCL2L1 and BAX transcripts) was significantly associated with grade 4 hematologic toxicity. RNA sequencing demonstrated little overlap in the top modulated peripheral blood transcripts between randomized arms.

CONCLUSIONS

Peripheral blood biomarkers relevant to radiation exposure demonstrate significant modulation after ¹³¹I-MIBG and concomitant radiation sensitizers affect extent of modulation. Biomarkers related to hematopoietic damage and apoptosis were associated with hematologic toxicity.

A192 EFFICACY OF USTEKINUMAB IN SMALL BOWEL STRICTURES OF FIBROSTENOTIC CROHN'S DISEASE AS ASSESSED BY INTESTINAL ULTRASOUND

Background

Small bowel Crohn’s disease (CD) strictures can lead to debilitating obstructive symptoms and the deterioration of quality of life. Imaging modalities such as intestinal ultrasound (IUS) are invaluable in the diagnosis of strictures. The use of IUS in CD is rapidly growing, is cost-effective, easily repeatable, and similar in accuracy to magnetic resonance enterography. Evidence for medical management of fibrostenotic CD has been limited to anti-tumor necrosis factor biologics. Studies on the efficacy of other biologic therapies for strictures such as ustekinumab, a p40/interleukin 12 and 23 inhibitor, are lacking.

Purpose

The objective of this study was to evaluate the efficacy of ustekinumab in the treatment of small bowel strictures on IUS.

Method

This retrospective cohort study evaluated the IUS changes of terminal ileal (TI) CD strictures at baseline and 12 months following ustekinumab initiation from 2016 to 2020 at a single tertiary care center. Strictures identified were defined as 1) increased bowel wall thickness (BWT) > 3mm, 2) narrowed luminal apposition, and 3) presence of pre-stenotic dilation (PSD) or the inability to pass the colonoscope through the narrowed area. Changes in sonographic parameters (BWT, luminal size, PSD, length, hyperemia, inflammatory fat, dysfunctional peristalsis) were recorded at baseline prior to initiation of ustekinumab and compared 12 months after treatment. Differences from baseline to 12 months were paired within-person and statistical analysis was performed using paired T-tests for continuous variables and McNemar’s test for categorical variables.

Result(s)

Of the 18 patients identified, 55% (n = 10) were male, median age was 49 years (Q1-Q3: 33-63 years) at initial scan, with median CD duration of 10 years (Q1-Q3: 8-20 years). The majority of TI strictures were surgically naïve (67%, n = 12). Between pre- and 12-month post ustekinumab therapy scans, there was significant improvement in BWT [8.2 mm vs 7.2 mm, p = 0.048], however there was no significant difference in the presence of peri-enteric inflammatory fat (p = 0.10), mean stricture length (17.7 vs 21.7 cm, p = 0.18), and mean stricture lumen diameter (3.3 mm vs 2.7 mm, p = 0.44) (Table 1). There was also no significant difference in the presence of stricture-associated peri-enteric fat (89% vs 67%, p = 0.10), stricture-associated hyperemia (83% vs 89%, p = 0.65) or dysfunctional peristalsis (50% vs 61%, p = 0.41) (Table 1).

Image

Conclusion(s)

Our study is the first to report the efficacy of ustekinumab in small bowel CD strictures using IUS at baseline and 12 months. This study shows that although ustekinumab leads to improvement in overall sonographic appearance of bowel thickness, it does not improve luminal narrowing nor PSD, two hallmark criteria of fibrostenosis. More extensive studies with larger sample sizes evaluating ustekinumab, or combination therapies, are required to identify their role in stricturing CD.

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Disclosure of Interest

None Declared

Comparative efficacy of tannin-free grain sorghum varieties for the control of necrotic enteritis caused by Clostridium perfringens in broiler chickens

A 28-day battery cage study was conducted to test the efficacy of tannin-free grain sorghum varieties fed to Cobb 500 male broiler chickens (n = 512) and challenged with Eimeria maxima (EM) and Clostridium perfringens (CP). Birds were fed 1 of 8 treatments (corn, red/bronze, white/tan, or U.S. No. 2 sorghum) and were grouped by challenge method (challenged with EM/CP or unchallenged). On d 14, birds in the challenge group were orally inoculated with ∼5,000 oocysts of EM, and on d 19, 20, and 21, birds were given a broth culture of CP with ∼10⁸ CFU/mL once daily. On d 21, three birds were scored for the degree/presence of necrotic enteritis (NE) lesions. Birds and feed were group weighed (d 0, 14, 21, and 28) to calculate average feed intake (FI), body weight gain (BWG), and adjusted feed conversion ratio (AdjFCR). Intestinal integrity was assessed through histological analysis of intestinal tissues, and change in transcriptome was determined using mRNA-sequencing on intestinal mucosa. Relative concentrations of secondary metabolites in grain sorghum were determined by LC-MS/MS analysis. Data were analyzed as a 2-way ANOVA with factors of treatment, challenge and their interaction. Regardless of challenge from 14 to 21 d, birds on the corn, white/tan, and U.S. No. 2 treatments were more efficient than those fed red/bronze treatment (P = 0.0026). From 14 to 28 d, BWG was significantly higher for the white/tan treatment (P = 0.024) compared to the red/bronze treatment. At 21 d, a significant interaction was observed for lesion score (P = 0.0001) in which, challenged birds fed red/bronze and white/tan treatments had reduced intestinal lesions compared to U.S. No. 2 and corn treatments. No differences among treatments were observed in jejunum morphology, but differential expression analysis showed an upregulation in defense response to bacteria and biotic stress in the challenged red/bronze treatment compared to the challenged corn. This study demonstrated improved gut health and minimal impact on growth and efficiency of broilers fed select grain sorghum varieties when challenged with EM/CP.

Trends in osteoporosis diagnosis and management in Australia

Trends in bone mineral density monitoring, and drug treatment for osteoporosis, in Australia were examined. Rates of DEXA scanning have increased in response to changes to government policy affecting reimbursement. The drug denosumab is being utilised at an increasing rate, while bisphosphonate use has declined. Osteoporosis prevalence remained stable over the same timeframe, while rate of hip fractures declined, suggesting that introduction of osteoporosis screening was associated with a reduction in adverse osteoporosis outcomes, but may also have been associated with overutilisation.

INTRODUCTION

Radiology interventions to diagnose and medications to manage osteoporosis in Australia are reimbursed under the Medicare benefits schedule (MBS) and Pharmaceutical Benefits Scheme (PBS). Monitoring of these databases enables changes in utilisation of these practices to be monitored over time.

METHODS

This study examined rates of utilisation for bone mineral density (BMD) measurement and osteoporosis pharmacotherapy subsidised under the MBS. Rates of osteoporosis and hip fracture were estimated using data reported by the Australian Bureau of Statistics (ABS) and Australian Institute for Health and Welfare (AIHW).

RESULTS

Rates of BMD measurement increased since the technology was first reimbursed, with changes to policy regarding reimbursement for screening for individuals over 70 leading to an increase in BMD measurement after 2007. Prescribing rates also increased over time, initially with the introduction of oral bisphosphonates and subsequently for denosumab, which has subsequently become the most commonly prescribed agent for osteoporosis management in Australia, while bisphosphonate use has declined. Osteoporosis prevalence in Australia has remained relatively static at 3-4% of the population since 2001 to 2017, while rates of minimal trauma hip fracture hospitalisations have declined from 195 per 100,000 to 174 per 100,000 in the same timeframe.

CONCLUSION

Available data indicates that osteoporosis screening rates changed over time from 2001 to 2018 and that changes to government policy had a significant effect on the rates at which screening was performed. Over the same timeframe, there was a sustained reduction in hip fracture hospitalisation rates, with no change to reported osteoporosis prevalence. This suggests that policy changes permitting unlimited access to BMD measurement were associated with a reduction in osteoporotic fractures, but may also have been associated with overutilisation. Prospective studies to assess the efficacy of specific policies to ensure screening is performed in accordance with best-practice guidelines may be desirable.

Participation in paid and unpaid work one year after injury and the impact of subsequent injuries for Māori: Results from a longitudinal cohort study in New Zealand

INTRODUCTION

Indigenous populations experience greater injury burdens than non-indigenous groups. This paper investigated, for injured Māori (New Zealand's indigenous population): 1) participation in paid and unpaid work 12 months after injury, 2) whether subsequent injuries are predictive of reduced participation, and 3) if particular characteristics of subsequent injuries predict reduced participation.

METHODS

The Subsequent Injury Study utilised data from the earlier Prospective Outcomes of Injury Study, a study of 2856 injured New Zealanders (including 566 Māori; 20%) who had an Accident Compensation Corporation (ACC; New Zealand's no-fault injury insurer) entitlement claim (sentinel injury). Data about subsequent injuries reported to ACC and hospital discharge data for injuries resulting in hospitalisation were also utilised. Multivariable models were used to examine if certain aspects of subsequent injury predicted either of two outcomes - reduced participation in paid, and unpaid work 12 months after a sentinel injury.

RESULTS

Eligible participants were identified from the 405 Māori participants interviewed at 12 months. Thirty-two percent sustained at least one ACC subsequent injury, and 16% reported reduced participation in unpaid work. Of the eligible participants working for pay at the time of their sentinel injury, 35% reported reduced participation in paid work. Although the relationship between sustaining a subsequent injury (or not) and reduced participation in paid work was unclear (aRR 1.4, 95%CI 0.9,2.3), particular subsequent injury characteristics were identified as being independently predictive: subsequent injury resulting from an assault (aRR 2.4, 95%CI 1.2,4.9), a subsequent injury involving an entitlement claim (aRR 2.0, 95%CI 1.1,3.4), sustaining more than one subsequent injury (aRR 2.0, 95%CI 1.1,3.6), and only non-work-related subsequent injuries (aRR 1.6, 95%CI 1.0,2.7).

CONCLUSIONS

Reduced participation in paid work is prevalent for Māori after an ACC entitlement claim injury. Particular characteristics of subsequent injuries after such an event impacts on participation in paid work 12 months after the sentinel injury, but the picture is less clear for unpaid work. Understanding the changes in paid and unpaid work, and the predictive characteristics of subsequent injuries for injured Māori, is important for future injury prevention strategies and supporting return to work rehabilitation programmes, specifically for Māori.

Perspective: Challenges in the Aerospace Marketplace and Growth Opportunities for Thermal Spray

The market needs for increased engine efficiency and environmentally friendly solutions remain the key drivers for the aerospace industry. These efficiency gains will be achieved by meeting the challenges of higher engine operating temperatures, weight reduction, and novel surface solutions for increased component longevity. A critical question to address is if the thermal spray (TS) industry can continue to meet the challenges and demands seen by the airlines and the engine manufacturers. In addition to non-aerospace influences, the COVID-19 pandemic has dramatically affected the landscape of industry growth, not only directly on airlines but also on the associated supply chain. This article reviews this market, its suppliers, and identifies the challenges and opportunities for future growth. Primary focus is on technology and what will be required to bring about reliable, robust, and cost-effective TS solutions into the marketplace. Several issues affecting the global landscape of the aerospace industry are discussed including (1) sustainability, (2) technology, (3) cost of ownership, (4) evolving marketplace, (5) workforce and behavior, and (6) supply chain vitality. An important question to address is if the TS industry can accelerate development with its supply chain and have the ability to commercialize technology more efficiently. Despite the market setbacks from the pandemic and previous issues with the Boeing 737 MAX fleet, the aerospace industry is poised to make significant advancements. These will create new opportunities for thermal spray technology in materials, equipment, and processes. To deliver on them, the implementation of Industry 4.0 along with the investment in human resources is more critical than ever. Based on the findings, the authors project a bright long-term future for both the aerospace and thermal spray industries.

384 Local Closed Loop Audit: COVID-19 Screening Before Endoscopic Ultrasound

Aim

Endoscopic Ultrasound (EUS) is one of the important diagnostic tests in patients with probable hepatobiliary or lung diseases. As it is an airborne procedure and due to the current COVID-19 pandemic, British Society of Gastroenterology and NICE guidelines have stated that patients who are undergoing EUS must be tested for COVID-19 within 3 days before the procedure. EUS must be considered deferring if the patient tests positive. The aim of this audit is to increase the proportion of patients being swabbed within 3 days/72 hours of the procedure to > 90% by the end of 2021.

Method

A list of patients who underwent elective EUS in January (initial audit) and mid-May to mid-June (re-audit) were collected using Endosoft software. Afterwards, electronic patient record system was checked for the date of the COVID-19 swab and its results. This data was then recorded in a password-protected Excel spreadsheet and the proportion of the patients meeting the standard was calculated.

Results

The results of the initial audit indicated that although 95.7% of swabs were done within 3 days of the procedure, only 40.9% were done within 72 hours. These results were discussed at a mortality and morbidity meeting, and recommendations were. Hence, in the re-audit, 98.4% of the swabs were done within 3 days of the procedure and the percentage of swabs being done within 72 hours increased to 95.2%.

Conclusions

The target of increasing the proportion of patients being swabbed within 3 days/72 hours of the EUS procedure to > 90% was met in mid-2021.

396 Rotator Cuff Assessment Following Traumatic Anterior Shoulder Dislocation

Aim

Glenohumeral joint dislocation is the most common traumatic joint dislocation with a high recurrence rate correlating with age at first dislocation. There is an associated increased incidence in concurrent rotator cuff tears with increasing age affecting 40% aged 40–60. Patient care was assessed against BESS/BOA standard: These patients should have rotator cuff assessment and those aged 40–60 should undergo routine MRI/Ultrasound imaging.

Method

All patients admitted to the emergency departments of the 3 Lanarkshire hospitals undergoing first time traumatic anterior dislocation of the shoulder in February 2021 were included. This was the third cycle of this audit. Previous interventions were presentation at a CPD meeting after cycle one and an NHS Lanarkshire regional meeting after cycle two.

Results

Cycle one (2018)-14 patients. 3/14 underwent rotator cuff assessment. 5/14 aged 40–60. 1/5 underwent rotator cuff imaging.

Cycle two (2020)-11 patients. 0/9 underwent rotator cuff assessment (Two excluded as managed operatively). 4/11 aged 40–60. 0/4 underwent rotator cuff imaging.

Cycle three (2021)-13 patients. 3/11 underwent rotator cuff assessment (Two excluded as managed operatively). 3/13 aged 40–60. 0/3 underwent rotator cuff imaging.

Conclusions

Although a slight improvement has been made over the 3 cycles with rotator cuff assessment the BOA standard is not being met. There has been no improvement in the additional imaging required in traumatic anterior shoulder dislocations in those aged 40–60 over the 3 cycles. These patients may develop pain, reduced function, and rotator cuff arthropathy. There is now an aim to introduce a pathway for these patients across the health board.

Opioid and Multi-Drug Pediatric Dental Sedation: A Narrative Review

Pharmacological behavior guidance has long been a mainstay of pediatric dental care. Behavioral limitations of very young children and dental fear in adolescents and children with special health care needs have made sedation and general anesthesia important to quality care delivery for these populations. The purposes of this review are to provide a broad perspective on the historical and contemporary use of sedation in pediatric dentistry, summarize available data on the safety and efficacy of opioid and multi-drug moderate sedation protocols, and consider the growing role of minimal intervention dentistry and the importance of patient and medication selection.

Complete splenic infarction in association with COVID-19

COVID-19 predominantly affects the respiratory system. As a novel disease, understanding of its management and complications continues to grow. Herein, we present a case of almost complete splenic infarction in a patient with COVID-19 pneumonia. This case highlights the need to maintain diagnostic vigilance whilst investigating secondary complications of COVID-19. It is also important to stress the high incidence of thromboembolic complications in patients with COVID-19, which may occur anywhere in the vasculature.

25 years of RIFE-a brief history and highlights

In 2020, the UK environmental regulators and food safety agencies, published the 25th edition of the Radioactivity in Food and the Environment (RIFE) report. This marks a quarter of a century since the landmark RIFE report was first published by the Ministry of Agriculture, Fisheries and Food in 1996, which represented the first joint monitoring and assessment report for the United Kingdom. This paper provides a summary of the RIFE report, how it has evolved and presents some case studies from over the 25 year period.

1607 Seeing White: Management of TIVA During Autologous Breast Reconstruction

Background

Free flap surgery has inherent risks, and the venous drainage of the Deep Inferior Epigastric Perforator (DIEP) flap is particularly vulnerable to congestion. In these cases, an algorithm for flap salvage should be followed and one of the final steps in this process is a cephalic vein transposition.

Case Report

We describe two patients undergoing mastectomy and immediate bilateral DIEP breast reconstruction, where cephalic vein transposition was required. As part of the Enhanced Recovery After Surgery (ERAS) pathway, patients are anaesthetised with a continuous propofol infusion (Total Intravenous Anaesthesia; TIVA). When the cephalic vein was identified, the propofol infusion was visible within the vein, which would have interrupted TIVA if harvested. To maintain continuous TIVA infusion, the cannula was resited prior to harvest of the cephalic vein. The cephalic vein was anastomosed to the superficial inferior epigastric vein and resolution of the venous congestion was noted.

Conclusions

These cases although rare highlight the importance of robust preoperative planning and communication between the team and preparation for all eventualities to ensure patient safety and successful outcomes. These cases highlight the potential effects vein harvesting or transposition may have on the safe and effective delivery of anaesthetic agents and other medication. We hope these cases prompt a discussion in the preoperative stage for alternate strategies for monitoring and intravenous access in response to diversions from the standard operating procedure.

Assessing the Current Research Infrastructure of Pediatric Dentistry Residency Programs: An Update for 2020

Purpose: To assess the research infrastructure of pediatric dentistry residency programs in the United States and to determine the variables associated with increased scholarly activity. Methods: A 21-item questionnaire assessing program characteristics, research infrastructure, publication output and grants secured, barriers to scholarly activity, and satisfaction with current research infrastructure was developed and administered to program directors from March through June 2020. Results: Of 94 programs, 43 (46 percent) responded; 22 (51 percent) were hospital-based (H), 15 (35 percent) combined hospital-university-based (C), and six (14 percent) university-based (U). Most programs (77 percent) offered protected time to residents with varying time allocation (P<0.001). Forty-four percent of programs did not offer any protected time for faculty (P=0.001). Median number of faculty publications, resident publications, and grants were highest for U (16, five, and five, respectively) and lowest for H (zero, zero, and zero) (P<0.001; P=0.03; P<0.001). Number of total full-time faculty, full-time board-certified faculty, and full-time faculty with advanced degrees were associated with increased publications and grants secured. Interference with revenue-generating clinical time was the largest barrier to publication. Conclusion: Although university-based programs exhibit the infrastructure most conducive to scholarly activity, these findings suggest pediatric dentistry residency programs may lack resources and infrastructure to generate high quality research.

Comparison of technical errors in pediatric bitewing radiographs acquired with round vs rectangular collimation

OBJECTIVE

To compare technical errors in bitewing radiographs acquired with round vs rectangular collimation in a hospital-based pediatric dentistry training program.

STUDY DESIGN

A retrospective chart review was conducted of 176 digital bitewing radiographs exposed with round collimation and 106 exposed with rectangular collimation. The number of re-exposures was calculated, and errors in central ray entry (CRE; "cone cuts"), horizontal and vertical positioning, and angulation were measured.

RESULTS

There were no greater re-exposures but significantly more CRE errors with rectangular collimation (21.7%; n = 23; 95% confidence interval [CI], 13.9%-30.0%) than with round collimation (3.4%; n = 6; 95% CI, 0.7%-6.1%). CRE error location, horizontal positioning errors, and size of horizontal overlapped contacts were statistically different but not clinically important.

CONCLUSIONS

Use of rectangular collimation resulted in increased CRE errors but no other clinically significant problems. This technique should be used to reduce radiation exposure to patients.

Association Between State-Based and Trait-Based Responsiveness to Satiety Cues Differs by Child Risk for Overweight/Obesity

Objectives

The relationship between parentally reported satiety responsiveness (i.e., trait) and laboratory-assessed satiety responsiveness (i.e., state) in children is not known, making it difficult to interpret and generalize lab-based findings. In addition, while many studies have shown weight-related differences in children's eating behaviors, less is known about appetitive traits that are present before obesity develops. Therefore, we examined associations between trait- and state-based satiety responsiveness among children with healthy weight who differed by familial risk for obesity.

Methods

Data from an ongoing longitudinal study were analyzed for 59 healthy-weight, 7–8 year-old children (BMI-for-age% &lt; 85). Familial risk for obesity was determined by parental weight status as low-risk (N = 34, both parents’ BMIs &lt; 25 kg/m2) or high-risk (N = 25, mothers’ BMI ≥ 30 kg/m2; fathers’ BMI ≥ 25 kg/m2). Parents completed the Children's Eating Behavior Questionnaire to assess satiety responsiveness (SR), a measure of children's tendency to stop eating once sated (trait). To assess state-based satiety, the Satiety Quotient (SQ) was calculated from an ad-libitum laboratory meal [(Pre-meal hunger – post-meal hunger)/meal intake in grams]. A higher SQ indicates a greater reduction in hunger per gram (i.e., better satiety responsiveness).

Results

Overall, SR and SQ were not correlated (P = 0.57). However, a linear regression controlling for pre-meal hunger and child BMI percentile revealed a risk status-by-SR interaction (β = 0.804, P = 0.04) such that SR was positively associated with SQ in high-risk children (95% CI [0.003, 0.430]), but there was no relationship between SR and SQ in low-risk children (95% CI [−0.203, 0.085]). No differences in SR, SQ, pre-meal hunger, or post-meal hunger were observed between risk groups.

Conclusions

Parentally reported (trait-based) satiety was positively associated with laboratory-assessed satiety, but only among healthy weight children at high-familial risk for obesity. Parents of children who are at high-risk for developing obesity may be more observant of children's appetitive traits compared to parents of low-risk children, and this may be helpful in the prevention of obesity.

Funding Sources

NIH RO1: DK110060.

A123 DEFINING CROHN’S DISEASE STRICTURES USING INTESTINAL ULTRASOUND COMPARED TO HISTOPATHOLOGY

Background

Fibrostenotic Crohn’s Disease (CD) is a challenging phenotype often leading to surgical resection. Diagnostic imaging is an invaluable tool to diagnose CD strictures. MRE (Magnetic Resonance Enterography) is the most widely used modality for evaluating strictures, but is limited by access and cost. The current definition of strictures is based only on MRE or CT (computed tomography). Strictures are defined as increased bowel wall thickness (BWT), narrowed luminal apposition, and pre-stenotic dilation &gt; 3cm according to CONSTRICT MR/CT expert consensus criteria. However, this definition has not been studied in intestinal US (IUS). IUS is a cost-effective, easily repeatable, and well-tolerated tool shown to have equal accuracy to MRE in diagnosing and monitoring CD.

Aims

The objective of this study was to assess the utility of identifying strictures with IUS using CONSTRICT definition.

Methods

In this retrospective pilot study, 30 of 80 CD patients who underwent small bowel resection (gold standard for stricture diagnosis) between 2015–2019 with IUS within 6 months prior to surgery were randomly identified for chart review. IUS was performed in a fasted state without oral contrast. Data extracted included confirmed stricture on resection specimens defined as having fibrosis and prestenotic dilation. Fistulizing disease was excluded. Student’s t-tests, sensitivities, specificities, positive (PNV) and negative predictive values (NPV) were calculated for IUS in detecting strictures.

Results

Of the 30 CD patients evaluated, 20 patients had fibrostenosis on pathology and IUS reports. Only 40% (8/20) met CONSTRICT criteria for stricture diagnosis on IUS, despite having a stricture on pathology. All patients had elevated BWT and luminal narrowing, but 60% (12/20) did not have prestenotic dilation &gt; 3cm. Mean dilation was 2.9 cm (SD 1.38) and was significantly different from the mean stricture diameter of 1.3cm (SD 0.59 cm, p=0.0001, 95% CI: 0.9–2.2). Mean BWT was 8.7 mm (SD: 2.5, range 5–15) where normal is &lt; 3mm, and mean luminal apposition was 2.3 mm (SD 1.2, range 0.2–5.8mm). IUS has a sensitivity of 95.2% (95% CI: 76.2 - 99.9%), specificity of 66.7% (95% CI: 29.9 - 92.5%), PPV of 87.0% (95% CI: 72.5–94.4), and NPV of 85.7% (95% CI 45.6–97.7%) in detecting strictures when compared to gold standard.

Conclusions

CONSTRICT criteria for diagnosing fibrostenotic CD on CT/MR may not be applicable to IUS. In this study, only 40% of patients met criteria despite having histologic confirmed strictures. Thus, perhaps additional criteria of stricture diameter &lt; 50% of prestenotic dilation size is most appropriate for IUS. This pilot study provides the initial data to delineate an IUS stricture definition for future validation and to inform both clinical practice and trial design.

Funding Agencies

None

Drill design using the 'control-chaos continuum': Blending science and art during return to sport following knee injury in elite football

Establishing the level of risk, planning and adapting the return to sport (RTS) process following a complex knee injury involves drawing on a combination of relevant high-quality evidence and practitioner experience. On-pitch rehabilitation is a critical element of this process, providing an effective transition from rehabilitation to team training. The 'control-chaos continuum' (CCC) is an adaptable framework for on-pitch rehabilitation moving from high control to high chaos, progressively increasing running load demands and incorporating greater perceptual and neurocognitive challenges within sport-specific drills. Drills are a key element of the CCC, and are designed to ensure specificity, ecological validity and maintaining player interest. We showcase drill progression through the phases of the CCC, highlighting the use of constraints to create drills that incorporate the physical, technical, tactical and injury-specific needs of the player. We also provide recommendations to help practitioners create training session content using the CCC to help replicate the demands of team training within their own environment.

Investigating Wilms' Tumours Worldwide: A Report of the OxPLORE Collaboration-A Cross-Sectional Observational Study

BACKGROUND

Childhood cancer is neglected within global health. Oxford Pediatrics Linking Oncology Research with Electives describes early outcomes following collaboration between low- and high-income paediatric surgery and oncology centres. The aim of this paper is twofold: to describe the development of a medical student-led research collaboration; and to report on the experience of Wilms' tumour (WT).

METHODS

This cross-sectional observational study is reported as per STROBE guidelines. Collaborating centres included three tertiary hospitals in Tanzania, Rwanda and the UK. Data were submitted by medical students following retrospective patient note review of 2 years using a standardised data collection tool. Primary outcome was survival (point of discharge/death).

RESULTS

There were 104 patients with WT reported across all centres over the study period (Tanzania n = 71, Rwanda n = 26, UK n = 7). Survival was higher in the high-income institution [87% in Tanzania, 92% in Rwanda, 100% in the UK (X² 36.19, p < 0.0001)]. Given the short-term follow-up and retrospective study design, this likely underestimates the true discrepancy. Age at presentation was comparable at the two African sites but lower in the UK (one-way ANOVA, F = 0.2997, p = 0.74). Disease was more advanced in Tanzania at presentation (84% stage III-IV cf. 60% and 57% in Rwanda and UK, respectively, X² 7.57, p = 0.02). All patients had pre-operative chemotherapy, and a majority had nephrectomy. Post-operative morbidity was higher in lower resourced settings (X² 33.72, p < 0.0001). Methodology involving medical students and junior doctors proved time- and cost-effective. This collaboration was a valuable learning experience for students about global research networks.

CONCLUSIONS

This study demonstrates novel research methodology involving medical students collaborating across the global south and global north. The comparison of outcomes advocates, on an institutional level, for development in access to services and multidisciplinary treatment of WT.

A "Verbal Thermometer" for Assessing Neurodegenerative Disease: Automated Measurement of Pronoun and Verb Ratio from Speech

Clinicians often use speech to characterize neurodegenerative disorders. Such characterizations require clinical judgment, which is subjective and can require extensive training. Quantitative Production Analysis (QPA) can be used to obtain objective quantifiable assessments of patient functioning. However, such human-based analyses of speech are costly and time consuming. Inexpensive off-the-shelf technologies such as speech recognition and part of speech taggers may avoid these problems. This study evaluates the ability of an automatic speech to text transcription system and a part of speech tagger to assist with measuring pronoun and verb ratios, measures based on QPA. Five participant groups provided spontaneous speech samples. One group consisted of healthy controls, while the remaining groups represented four subtypes of frontotemporal dementia. Findings indicated measurement of pronoun and verb ratio was robust despite errors introduced by automatic transcription and the tagger and despite these off-the-shelf products not having been trained on the language obtained from speech of the included population.

Microplastics and other anthropogenic particles in the surface waters of the Chesapeake Bay

Microplastics are a ubiquitous environmental contaminant whose distributions have been correlated with land-use and population density. Although there are numerous studies quantifying microplastics in the environment, local studies help inform sources, pathways, and policy. Here, we measure the concentration of microplastics in the surface waters across the Chesapeake Bay - the largest estuary in the USA. Thirty surface water samples from throughout the Chesapeake Bay were collected with a manta trawl. Samples were manually processed for microplastics and other anthropogenic particles. Fourier-transform infrared spectroscopy (FTIR) was used to determine the chemical composition of the particles. Higher concentrations were found near major cities and where larger rivers or tributaries met the Chesapeake Bay. Fragments, films, and fibres were the most common morphologies found, and polyethylene and polypropylene were the most common plastic types. These results can be used to inform mitigation strategies for microplastic pollution in the Chesapeake Bay region.

Comparison of two Meglumine-Diatrizoate based bowel preparations for computed tomography colonography: Comparison of patient symptoms and bowel preparation quality

INTRODUCTION

To investigate the impact of two Meglumine-Diatrizoate based bowel preparation regimes for computed tomography colonography (CTC) on the patient experience and image quality.

METHODS

100 patients consumed Meglumine-Diatrizoate at 24 h and 12 h prior to the CTC examination. 50 patients followed regime 1 (50:50), 50 ml of Meglumine-Diatrizoate at both 24 and 12 h prior to the examination. 50 patients followed regime 2 (75:25), 75 ml of Meglumine-Diatrizoate at 24 h prior to the examination and 25 ml of Meglumine-Diatrizoate at 12 h prior to the examination. All patients completed a questionnaire to indicate the time of onset of adverse effects and when they were most severe. Five advanced practitioners assessed the image quality in a visual grading study. Visual grading characteristic (VGC) analysis was applied with regime 1 as the reference condition and regime 2 and test condition; test alpha was set at 0.05.

RESULTS

Image quality was assessed with successful bowel cleansing as the scoring criteria for the visual grading study. The bowel cleansing as provided by the two Meglumine-Diatrizoate regimes was revealed not to be statistically different, with the area under the VGC curve and 95% confidence intervals 0.487 (0.287, 0.701), p = 0.887. Patients taking the 75:25 bowel preparation experienced a shorter median time to the onset of adverse effects.

CONCLUSION

There was no observed difference in Image quality criteria score for the two Meglumine-Diatrizoate based bowel preparation with more predictable adverse effects of Meglumine-Diatrizoate with the 75:25 preparation.

IMPLICATIONS FOR PRACTICE

Providing patients with a higher contrast burden 24 h prior to CTC may have a positive impact on the patient experience without compromising image quality.

Developing and implementing a faculty development curriculum for Japanese family medicine residency faculty

BACKGROUND

Despite the increase in family medicine residency in Japan, there are only a few structured faculty development (FD) programs. The objective of this project was to construct a consensus on core competencies of faculty to develop a faculty development curriculum in a Japanese family medicine context.

METHODS

In 2015, a private FD initiative in the Mie University initiated a curriculum development in collaboration with FD fellowship at the University of Pittsburgh. A literature review and subsequent Delphi process were conducted for core competency development. Based on the core competency list, we designed and implemented a 2-year part-time FD curriculum from 2016. A course evaluation using pre-post confidence level was held during March 2017.

RESULTS

Twenty-eight objectives were defined in five core domains: 1) care management/family medicine principle, 2) leadership/professional development, 3) administrative/management, 4) teaching, and 5) research/scholarly activity. A pre-post survey at the end of an academic year revealed a significant increase in learner confidence for "care management/family medicine principle" (P = .03), "teaching" (P < .01), and "research/scholarly activity" (P < .01), as well as the total score (P = .03).

CONCLUSIONS

A family medicine FD curriculum based on a faculty core competency list was developed by consensus in a Japanese family medicine context. The core competency was strongly context-oriented, and the relevance of the FD topics and opportunities to apply to the participants' current positions may be inevitable for learner engagement. Further curriculum refinements will be required to see whether the curriculum could be used for faculty development in other family medicine residencies.

Patient deprivation and perceived scan burden negatively impact the quality of whole-body MRI

AIM

To evaluate the association between the image quality of cancer staging whole-body magnetic resonance imaging (WB-MRI) and patient demographics, distress, and perceived scan burden.

MATERIALS AND METHODS

A sample of patients recruited prospectively to multicentre trials comparing WB-MRI with standard scans for staging lung and colorectal cancer were invited to complete two questionnaires. The baseline questionnaire, administered at recruitment, collated data on demographics, distress and co-morbidity. The follow-up questionnaire, completed after staging investigations, measured perceived WB-MRI scan burden (scored 1 low to 7 high). WB-MRI anatomical coverage, and technical quality was graded by a radiographic technician and grading combined to categorise the scan as "optimal", "sub-optimal" or "degraded". A radiologist categorised 30 scans to test interobserver agreement. Data were analysed using the chi-square, Fisher's exact, t-tests, and multinomial regression.

RESULTS

One hundred and fourteen patients were included in the study (53 lung, 61 colorectal; average age 65.3 years, SD=11.8; 66 men [57.9%]). Overall, 45.6% (n=52), scans were classified as "optimal" quality, 39.5% (n=45) "sub-optimal", and 14.9% (n=17) as "degraded". In adjusted analyses, greater deprivation level and higher patient-reported scan burden were both associated with a higher likelihood of having a sub-optimal versus an optimal scan (odds ratio [OR]: 4.465, 95% confidence interval [CI]: 1.454 to 13.709, p=0.009; OR: 1.987, CI: 1.153 to 3.425, p=0.013, respectively). None of the variables predicted the likelihood of having a degraded scan.

CONCLUSIONS

Deprivation and patients' perceived experience of the WB-MRI are related to image quality. Tailored protocols and individualised patient management before and during WB-MRI may improve image quality.

Primary paediatric chest wall tumours necessitating surgical management

INTRODUCTION

Limited literature exists on oncological chest wall reconstruction in the paediatric population, with the field still largely undecided on the best surgical reconstructive techniques to employ. The use of biological grafts/meshes is gaining popularity in certain adult surgical procedures but their use in paediatric procedures is rarely reported in the literature. We present the outcomes of our institution's multidisciplinary approach to managing paediatric chest wall tumours as well as our experience with the use of biological grafts for chest wall reconstruction following oncological resections.

METHODS

Data were analysed retrospectively from eight paediatric patients who were treated for primary chest wall tumours between 2010 and 2018.

RESULTS

The tumours comprised two lipoblastomas, three Ewing's sarcomas, an undifferentiated sarcoma with osteosarcomatous differentiation, a high grade undifferentiated sarcoma and a myofibroma. Seven of the eight patients underwent chest wall reconstruction with a biological graft. There were no postoperative mortalities and no evidence of recurrence in any of the patients in the series. No further chest wall operations were required and there were no postoperative infection related complications.

CONCLUSIONS

We support the use of biological grafts for chest wall reconstruction after oncological resections and maintain that a multidisciplinary approach is essential for the management of paediatric chest wall tumours.

Discovery of disease- and drug-specific pathways through community structures of a literature network

Motivation

In light of the massive growth of the scientific literature, text mining is increasingly used to extract biological pathways. Though multiple tools explore individual connections between genes, diseases and drugs, few extensively synthesize pathways for specific diseases and drugs.

Results

Through community detection of a literature network, we extracted 3444 functional gene groups that represented biological pathways for specific diseases and drugs. The network linked Medical Subject Headings (MeSH) terms of genes, diseases and drugs that co-occurred in publications. The resulting communities detected highly associated genes, diseases and drugs. These significantly matched current knowledge of biological pathways and predicted future ones in time-stamped experiments. Likewise, disease- and drug-specific communities also recapitulated known pathways for those given diseases and drugs. Moreover, diseases sharing communities had high comorbidity with each other and drugs sharing communities had many common side effects, consistent with related mechanisms. Indeed, the communities robustly recovered mutual targets for drugs [area under Receiver Operating Characteristic curve (AUROC)=0.75] and shared pathogenic genes for diseases (AUROC=0.82). These data show that literature communities inform not only just known biological processes but also suggest novel disease- and drug-specific mechanisms that may guide disease gene discovery and drug repurposing.

Availability and implementation

Application tools are available at http://meteor.lichtargelab.org.

Supplementary information

Supplementary data are available at Bioinformatics online.

Impact of Instituting General Anesthesia on Oral Sedation Care in a Tertiary Care Pediatric Dental Clinic

Tertiary pediatric medical centers disproportionately care for low-income, underserved children with significant dental needs. Long wait times for hospital operating room treatment increase tooth loss rather than restoration. Oral sedation has commonly been provided to avoid the long waits for operating room treatment. However, this can be challenging with young, anxious patients. High failure rates and repeat visits for oral sedation have resulted in continued waiting for definitive dental services in the operating room. The Division of Dentistry requested the Department of Anesthesiology to create a general anesthesia program in the dental clinic to increase the use of anesthesia services but align the cost of the anesthetic with the revenue stream. Our aim was to objectively measure the performance of a dental clinic anesthesia service by comparing the percentage of case completions, percentage of complete radiographs, and number of serious adverse events to clinic-based oral sedations. We were also interested in total number of cases completed. We retrospectively studied data regarding an in-office general anesthesia (IOGA) program for dentistry and compared it to oral sedations before and after instituting the IOGA program. Patients received either a general endotracheal anesthetic or nonintubated total intravenous general anesthesia. Successful case completion increased from 88.6% (oral sedation) to 99.5% (IOGA). One hundred percent of IOGA cases had complete radiographs, as opposed to 63.4% for oral sedation. This was an increase from 53.5% from the previous 2 years with oral sedation. Serious adverse event rate was 0% (0/508) for oral sedation and 0.2% (1/418) for IOGA. Comparing 2 years before and after IOGA revealed a decrease in oral sedations from 930 to 508, whereas IOGA increased from 0 to 418 cases. Anesthesia services in dental clinic increased complete dental care and complete radiographs, reduced failed sedations, and were performed safely.