A novel, robust peptidyl-lys metalloendopeptidase from Trametes coccinea recombinantly expressed in Komagataella phaffii

A novel peptidyl-lys metalloendopeptidase (Tc-LysN) from Tramates coccinea was recombinantly expressed in Komagataella phaffii using the native pro-protein sequence. The peptidase was secreted into the culture broth as zymogen (~38 kDa) and mature enzyme (~19.8 kDa) simultaneously. The mature Tc-LysN was purified to homogeneity with a single step anion-exchange chromatography at pH 7.2. N-terminal sequencing using TMTpro Zero and mass spectrometry of the mature Tc-LysN indicated that the pro-peptide was cleaved between the amino acid positions 184 and 185 at the Kex2 cleavage site present in the native pro-protein sequence. The pH optimum of Tc-LysN was determined to be 5.0 while it maintained ≥60% activity between pH values 4.5-7.5 and ≥30% activity between pH values 8.5-10.0, indicating its broad applicability. The temperature maximum of Tc-LysN was determined to be 60 °C. After 18 h of incubation at 80 °C, Tc-LysN still retained ~20% activity. Organic solvents such as methanol and acetonitrile, at concentrations as high as 40% (v/v), were found to enhance Tc-LysN's activity up to ~100% and ~50%, respectively. Tc-LysN's thermostability, ability to withstand up to 8 M urea, tolerance to high concentrations of organic solvents, and an acidic pH optimum make it a viable candidate to be employed in proteomics workflows in which alkaline conditions might pose a challenge. The nano-LC-MS/MS analysis revealed bovine serum albumin (BSA)'s sequence coverage of 84% using Tc-LysN which was comparable to the sequence coverage of 90% by trypsin peptides. KEY POINTS: •A novel LysN from Trametes coccinea (Tc-LysN) was expressed in Komagataella phaffii and purified to homogeneity •Tc-LysN is thermostable, applicable over a broad pH range, and tolerates high concentrations of denaturants •Tc-LysN was successfully applied for protein digestion and mass spectrometry fingerprinting.

Accelerating Medicines Partnership® Schizophrenia (AMP® SCZ): Rationale and Study Design of the Largest Global Prospective Cohort Study of Clinical High Risk for Psychosis

This article describes the rationale, aims, and methodology of the Accelerating Medicines Partnership® Schizophrenia (AMP® SCZ). This is the largest international collaboration to date that will develop algorithms to predict trajectories and outcomes of individuals at clinical high risk (CHR) for psychosis and to advance the development and use of novel pharmacological interventions for CHR individuals. We present a description of the participating research networks and the data processing analysis and coordination center, their processes for data harmonization across 43 sites from 13 participating countries (recruitment across North America, Australia, Europe, Asia, and South America), data flow and quality assessment processes, data analyses, and the transfer of data to the National Institute of Mental Health (NIMH) Data Archive (NDA) for use by the research community. In an expected sample of approximately 2000 CHR individuals and 640 matched healthy controls, AMP SCZ will collect clinical, environmental, and cognitive data along with multimodal biomarkers, including neuroimaging, electrophysiology, fluid biospecimens, speech and facial expression samples, novel measures derived from digital health technologies including smartphone-based daily surveys, and passive sensing as well as actigraphy. The study will investigate a range of clinical outcomes over a 2-year period, including transition to psychosis, remission or persistence of CHR status, attenuated positive symptoms, persistent negative symptoms, mood and anxiety symptoms, and psychosocial functioning. The global reach of AMP SCZ and its harmonized innovative methods promise to catalyze the development of new treatments to address critical unmet clinical and public health needs in CHR individuals.

Development of the PSYCHS: Positive SYmptoms and Diagnostic Criteria for the CAARMS Harmonized with the SIPS

AIM

To harmonize two ascertainment and severity rating instruments commonly used for the clinical high risk syndrome for psychosis (CHR-P): the Structured Interview for Psychosis-risk Syndromes (SIPS) and the Comprehensive Assessment of At-Risk Mental States (CAARMS).

METHODS

The initial workshop is described in the companion report from Addington et al. After the workshop, lead experts for each instrument continued harmonizing attenuated positive symptoms and criteria for psychosis and CHR-P through an intensive series of joint videoconferences.

RESULTS

Full harmonization was achieved for attenuated positive symptom ratings and psychosis criteria, and modest harmonization for CHR-P criteria. The semi-structured interview, named Positive SYmptoms and Diagnostic Criteria for the CAARMS Harmonized with the SIPS (PSYCHS), generates CHR-P criteria and severity scores for both CAARMS and SIPS.

CONCLUSIONS

Using the PSYCHS for CHR-P ascertainment, conversion determination, and attenuated positive symptom severity rating will help in comparing findings across studies and in meta-analyses.

Impact of opioid-free analgesia on pain severity and patient satisfaction after discharge from surgery: multispecialty, prospective cohort study in 25 countries

BACKGROUND

Balancing opioid stewardship and the need for adequate analgesia following discharge after surgery is challenging. This study aimed to compare the outcomes for patients discharged with opioid versus opioid-free analgesia after common surgical procedures.

METHODS

This international, multicentre, prospective cohort study collected data from patients undergoing common acute and elective general surgical, urological, gynaecological, and orthopaedic procedures. The primary outcomes were patient-reported time in severe pain measured on a numerical analogue scale from 0 to 100% and patient-reported satisfaction with pain relief during the first week following discharge. Data were collected by in-hospital chart review and patient telephone interview 1 week after discharge.

RESULTS

The study recruited 4273 patients from 144 centres in 25 countries; 1311 patients (30.7%) were prescribed opioid analgesia at discharge. Patients reported being in severe pain for 10 (i.q.r. 1-30)% of the first week after discharge and rated satisfaction with analgesia as 90 (i.q.r. 80-100) of 100. After adjustment for confounders, opioid analgesia on discharge was independently associated with increased pain severity (risk ratio 1.52, 95% c.i. 1.31 to 1.76; P < 0.001) and re-presentation to healthcare providers owing to side-effects of medication (OR 2.38, 95% c.i. 1.36 to 4.17; P = 0.004), but not with satisfaction with analgesia (β coefficient 0.92, 95% c.i. -1.52 to 3.36; P = 0.468) compared with opioid-free analgesia. Although opioid prescribing varied greatly between high-income and low- and middle-income countries, patient-reported outcomes did not.

CONCLUSION

Opioid analgesia prescription on surgical discharge is associated with a higher risk of re-presentation owing to side-effects of medication and increased patient-reported pain, but not with changes in patient-reported satisfaction. Opioid-free discharge analgesia should be adopted routinely.

Transcriptional Factors Mediated Reprogramming to Pluripotency

A unique kind of pluripotent cell, i.e., Induced pluripotent stem cells (iPSCs), now being targeted for iPSC synthesis, are produced by reprogramming animal and human differentiated cells (with no change in genetic makeup for the sake of high efficacy iPSCs formation). The conversion of specific cells to iPSCs has revolutionized stem cell research by making pluripotent cells more controllable for regenerative therapy. For the past 15 years, somatic cell reprogramming to pluripotency with force expression of specified factors has been a fascinating field of biomedical study. For that technological primary viewpoint reprogramming method, a cocktail of four transcription factors (TF) has required: Kruppel-like factor 4 (KLF4), four-octamer binding protein 34 (OCT3/4), MYC and SOX2 (together referred to as OSKM) and host cells. IPS cells have great potential for future tissue replacement treatments because of their ability to self-renew and specialize in all adult cell types, although factor-mediated reprogramming mechanisms are still poorly understood medically. This technique has dramatically improved performance and efficiency, making it more useful in drug discovery, disease remodeling, and regenerative medicine. Moreover, in these four TF cocktails, more than 30 reprogramming combinations were proposed, but for reprogramming effectiveness, only a few numbers have been demonstrated for the somatic cells of humans and mice. Stoichiometry, a combination of reprogramming agents and chromatin remodeling compounds, impacts kinetics, quality, and efficiency in stem cell research.

No Sex Differences in Mechanical Thrombectomy Time Metrics and Outcomes in Saskatchewan

BACKGROUND AND PURPOSE

Numerous studies have shown longer pre-hospital and in-hospital workflow times and poorer outcomes in women after acute ischemic stroke (AIS) in general and after endovascular treatment (EVT) in particular. We investigated sex differences in acute stroke care of EVT patients over 5 years in a comprehensive Canadian provincial registry.

METHODS

Clinical data of all AIS patients who underwent EVT between January 2017 and December 2022 in the province of Saskatchewan were captured in the Canadian OPTIMISE registry and supplemented with patient data from administrative data sources. Patient baseline characteristics, transport time metrics, and technical EVT outcomes between female and male EVT patients were compared.

RESULTS

Three-hundred-three patients underwent EVT between 2017 and 2022: 144 (47.5%) women and 159 (52.5%) men. Women were significantly older (median age 77.5 [interquartile range: 66-85] vs.71 [59-78], p < 0.001), while men had more intracranial internal carotid artery occlusions (48/159 [30.2%] vs. 26/142 [18.3%], p = 0.03). Last-known-well to comprehensive stroke center (CSC)-arrival time (median 232 min [interquartile range 90-432] in women vs. 230 min [90-352] in men), CSC-arrival-to-reperfusion time (median 108 min [88-149] in women vs. 102 min [77-141] in men), reperfusion status (successful reperfusion 106/142 [74.7%] in women vs. 117/158 [74.1%] in men) as well as modified Rankin score at 90 days did not differ significantly. This held true after adjusting for baseline variables in multivariable analyses.

CONCLUSION

While women undergoing EVT in the province of Saskatchewan were on average older than men, they were treated just as fast and achieved similar technical and clinical outcomes compared to men.

Development of the PSYCHS: Positive SYmptoms and Diagnostic Criteria for the CAARMS Harmonized with the SIPS

Aim

To harmonize two ascertainment and severity rating instruments commonly used for the clinical high risk syndrome for psychosis (CHR-P): the Structured Interview for Psychosis-risk Syndromes (SIPS) and the Comprehensive Assessment of At-Risk Mental States (CAARMS).

Methods

The initial workshop is described in the companion report from Addington et al. After the workshop, lead experts for each instrument continued harmonizing attenuated positive symptoms and criteria for psychosis and CHR-P through an intensive series of joint videoconferences.

Results

Full harmonization was achieved for attenuated positive symptom ratings and psychosis criteria, and partial harmonization for CHR-P criteria. The semi-structured interview, named P ositive SY mptoms and Diagnostic Criteria for the C AARMS H armonized with the S IPS (PSYCHS), generates CHR-P criteria and severity scores for both CAARMS and SIPS.

Conclusion

Using the PSYCHS for CHR-P ascertainment, conversion determination, and attenuated positive symptom severity rating will help in comparing findings across studies and in meta-analyses.

Preclinical Large Animal Porcine Models for Cardiac Regeneration and Its Clinical Translation: Role of hiPSC-Derived Cardiomyocytes

Myocardial Infarction (MI) occurs due to a blockage in the coronary artery resulting in ischemia and necrosis of cardiomyocytes in the left ventricular heart muscle. The dying cardiac tissue is replaced with fibrous scar tissue, causing a decrease in myocardial contractility and thus affecting the functional capacity of the myocardium. Treatments, such as stent placements, cardiac bypasses, or transplants are beneficial but with many limitations, and may decrease the overall life expectancy due to related complications. In recent years, with the advent of human induced pluripotent stem cells (hiPSCs), newer avenues using cell-based approaches for the treatment of MI have emerged as a potential for cardiac regeneration. While hiPSCs and their derived differentiated cells are promising candidates, their translatability for clinical applications has been hindered due to poor preclinical reproducibility. Various preclinical animal models for MI, ranging from mice to non-human primates, have been adopted in cardiovascular research to mimic MI in humans. Therefore, a comprehensive literature review was essential to elucidate the factors affecting the reproducibility and translatability of large animal models. In this review article, we have discussed different animal models available for studying stem-cell transplantation in cardiovascular applications, mainly focusing on the highly translatable porcine MI model.

Desired Qualities of Endovascular Tools and Barriers to Treating Medium Vessel Occlusion MeVO : Insights from the MeVO-FRONTIERS International Survey

BACKGROUND

Endovascular treatment (EVT) for stroke due to medium vessel occlusion (MeVO) can be technically challenging and specific endovascular tools are needed to safely and effectively recanalize these relatively small and fragile vessels. We aimed to gain insight into availability and desired qualities of endovascular devices used in MeVO stroke and examined barriers to adoption of MeVO EVT in clinical practice on a global scale.

METHODS

We conducted a case-based international survey among neurointerventionalists. As a part of the survey, participants were asked whether they felt appropriate endovascular tools for MeVO stroke exist and are available to them in their clinical practice. We then examined barriers to adopting MeVO EVT and analyzed them by geographic regions.

RESULTS

A total of 263 neurointerventionists participated, of which 178 (67.7%) and 83 (31.6%) provided responses on desired qualities of MeVO EVT tools and on barriers to their adoption in local practice, respectively. The majority 121/178 (68%) felt there was substantial room for improvement regarding existing tools. A large proportion 131/178 (73.6%) felt they had appropriate access to existing tools. The most commonly mentioned barrier for adopting MeVO EVT in North America was "awaiting better tools" (9/28 responses, 32.1%), while "awaiting better evidence" (8/26 responses, 30.8%), and the need for improved "funding" (7/26 responses, 26.9%) were important barriers in Europe.

CONCLUSION

The majority of surveyed neurointerventionalists felt that dedicated MeVO EVT tools can be substantially improved upon. Different regions face various challenges in adoption of MeVO EVT, but overall, physicians are mostly awaiting better MeVO EVT tools.

Modulation of Mitochondrial Bioenergetics by Polydopamine Nanoparticles in Human iPSC-Derived Cardiomyocytes

Myocardial infarction (MI) leads to the formation of an akinetic scar on the heart muscle causing impairment in cardiac contractility and conductance, leading to cardiac remodeling and heart failure (HF). The current pharmacological approaches for attenuating MI are limited and often come with long-term adverse effects. Therefore, there is an urgent need to develop novel multimodal therapeutics capable of modulating cardiac activity without causing any major adverse effects. In the current study, we have demonstrated the applicability of polydopamine nanoparticles (PDA-NPs) as a bioactive agent that can enhance the contractility and beat propagation of human-induced pluripotent stem cell-derived cardiomyocytes (hiPSC-CMs). Treatment of hiPSC-CMs with PDA-NPs demonstrated accumulation of the latter into mitochondria and significantly enhanced time-dependent adenosine triphosphate (ATP) production in these cells, indicating improved mitochondrial bioenergetics. Furthermore, the effect of PDA-NPs on hiPSC-CM activity was evaluated by measuring calcium transients. Treatment with PDA-NPs increased the calcium cycling in hiPSC-CMs in a temporal manner. Our results demonstrated a significant reduction in peak amplitude, transient duration, time to peak, and transient decay time in the PDA-NPs-treated hiPSC-CMs as compared to untreated hiPSC-CMs. Additionally, treatment of isolated perfused rat heart ex vivo with PDA-NPs demonstrated cardiotonic effects on the heart and significantly improved the hemodynamic function, suggesting its potential for enhancing whole heart contractility. Lastly, the gene expression analysis data revealed that PDA-NPs significantly upregulated cardiac-specific genes (ACADM, MYL2, MYC, HCN1, MYL7, GJA5, and PDHA1) demonstrating the ability to modulate genetic expression of cardiomyocytes. Taken together, these findings suggest PDA-NPs capability as a versatile nanomaterial with potential uses in next-generation cardiovascular applications.

Focused ultrasound stimulation of the inflammatory reflex at the spleen ameliorates pulmonary arterial hypertension in rodents

Background

Inflammation is a major contributor in pulmonary arterial hypertension (PAH) pathogenesis. Non-invasive, focused ultrasound stimulation (FUS) of the spleen activates the neuroimmune inflammatory reflex (IR) and suppresses systemic inflammation [1].

Purpose

We aimed to explore whether daily FUS of the spleen improves haemodynamics and biomarkers by modulating the IR, in a rat model of PAH.

Methods

Sprague-Dawley rats (n=12) were injected s.c. with Sugen5416 (VEGF receptor inhibitor) and then, were placed in a hypoxic chamber (FiO2=10%) for 21 days, followed by 14 days of re-exposure to normoxia (FiO2=10%). At day 21, rats were randomized to either FUS (n=6) or sham-stimulation of the spleen (n=6). Each FUS- or sham-stimulation session consisted of 12 minutes. After 14 days of treatment, in a terminal experiment, right ventricular systolic pressure (RVSP) and arterial pressure were measured invasively, as well as biomarkers, in each animal (Figure 1A).

Results

FUS significantly reduced RVSP compared with the sham-stimulation (Mean±SEM, 50.83±3.57 mmHg vs 72.50±5.81; p=0.009), resulting in a 30% relative reduction (Figure 1B). Mean systemic arterial pressure was similar in the 2 groups (Mean±SEM, 79.83±3.73 mmHg vs. 87.00±2.95; p=0.137) (Figure 1C), as was the change in heart rate between day 1 and day 14 of treatment period (−19.53±5.36% vs. −16.79±3.1, p=0.61) (Figure 1D). Consistently, plasma brain natriuretic peptide (BNP) levels are reduced in the FUS group (119.45±19.93 ng/μl vs. 319.39±91.85; p=0.019), indicative of reduced myocardial wall stress in the FUS group (Figure 1E).

Conclusion

Non-invasive FUS of the spleen reduced RVSP by ∼30% and BNP without significantly affecting systemic pressure or heart rate, in rats with severe PAH. Non-invasive FUS, by modulating the IR, may exert an anti-inflammatory effect in PAH. FUS of the spleen is noninvasive, safe, widely available and easy to perform, and should be further explored as a possible therapeutic option in PAH.

Funding Acknowledgement

Type of funding sources: Private hospital(s). Main funding source(s): Northwell Health

Purification and characterization of a fungal aspartic peptidase from Trichoderma reesei and its application for food and animal feed protein hydrolyses

BACKGROUND

Various neutral and alkaline peptidases are commercially available for use in protein hydrolysis under neutral to alkaline conditions. However, the hydrolysis of proteins under acidic conditions by applying fungal aspartic peptidases (FAPs) has not been investigated in depth so far. The aim of this study, thus, was to purify a FAP from the commercial enzyme preparation, ROHALASE® BXL, determine its biochemical characteristics, and investigate its application for the hydrolysis of food and animal feed proteins under acidic conditions.

RESULTS

A Trichoderma reesei derived FAP, with an apparent molecular mass of 45.8 kDa (sodium dodecyl sulfate-polyacrylamide gel electrophoresis; SDS-PAGE) was purified 13.8-fold with a yield of 37% from ROHALASE® BXL. The FAP was identified as an aspartate protease (UniProt ID: G0R8T0) by inhibition and nano-LC-ESI-MS/MS studies. The FAP showed the highest activity at 50°C and pH 4.0. Monovalent cations, organic solvents, and reducing agents were tolerated well by the FAP. The FAP underwent an apparent competitive product inhibition by soy protein hydrolysate and whey protein hydrolysate with apparent K_i -values of 1.75 and 30.2 mg*mL^-1 , respectively. The FAP showed promising results in food (soy protein isolate and whey protein isolate) and animal feed protein hydrolyses. For the latter, an increase in the soluble protein content of 109% was noted after 30 min.

CONCLUSION

Our results demonstrate the applicability of fungal aspartic endopeptidases in the food and animal feed industry. Efficient protein hydrolysis of industrially relevant substrates such as acidic whey or animal feed proteins could be conducted by applying fungal aspartic peptidases. © 2022 Society of Chemical Industry.

Abstract P1035: Co-culturing Human Induced Pluripotent Stem Cell-derived Cardiomyocytes With Mesenchymal Stem Cells Promotes Their Maturation And Enhances Cardioprotection Under Hypoxic Stress

Introduction: Co-culturing human induced pluripotent stem cell (hiPSC)-derived cardiomyocytes (hiCMs) with other stem/progenitor cells like bone-marrow mesenchymal stem cells (BM-MSCs) and endothelial progenitors has been shown to improve their survival post transplantation into ischemic hearts. Co-culturing with other cardiac cells has also shown to improve the maturation of hiCMs in vitro. However, the potential of co-culturing hiPSC-derived MSCs (hiMSCs) for hiCM maturation and cardioprotection has not been explored.

Hypothesis: We hypothesize that co-culturing of hiMSCs with hiCMs significantly alters the cells’ proteome, improves hiCM maturation, and enhances cardioprotection.

Results: hiCMs were co-cultured with hiMSCs for one week at a ratio of 3:1. To evaluate the effect of hiMSCs on hiCM maturation in the co-culture, changes in the hiCM function and gene expression were assessed via multi electrode array (MEA) analysis and qPCR, respectively. MEA analysis showed an increase in ADP50 and ADP90 in addition to improved response to cardiac drugs in hiCMs co-cultured with hiMSCs as compared to hiCM-only cultures, indicating improved maturation of hiCMs in the co-culture. Furthermore, gene expression analysis showed an increased expression of mature CM-associated genes (MYH7, TNNT2). When subjected to hypoxic stress (1% O 2 ), we also observed a significant decrease in the number of TUNEL positive cells in the co-cultures as compared to hiCM-only culture. Assessment of hiCM functionality via MEA analysis showed an improved cardioprotection in co-cultures as compared to the single cell-type cultures. Furthermore, proteomic analysis demonstrated increased expression of cardioprotective growth factors (GFs): HGF, VEGFA and IGFBP-1 in the conditioned medium of the co-cultured cells versus single cell-type cultures.

Conclusion: Overall, our results established that co-culturing hiCMs with hiMSCs improved cardioprotection via increased the expression of cardioprotective growth factors and enhanced the maturation of hiCMs in vitro.

17 Establishment of Virtual Fracture Clinic in Princess Royal Hospital Telford: Experience and Recommendations During the First 9 Months

Introduction

Virtual fracture clinics (VFC) have been shown to be a safe and cost-effective way of managing outpatient referrals to the orthopaedic department. During the coronavirus pandemic there has been a push to reduce unnecessary patient contact whilst maintaining patient safety.

Method

A protocol was developed by the clinical team on how to manage common musculoskeletal presentations to A&E prior to COVID as part of routine service development. Patients broadly triaged into 4 categories; discharge with advice, referral to VFC, referral to face to face clinic or discussion with on call team. The first 9 months of data were analysed to assess types of injury seen and outcomes.

Results

In total 2489 patients were referred to VFC from internal and external sources. 734 patients were discharged without follow-up and 182 patients were discharged for physiotherapy review. Only 3 patients required admission. Regarding follow-ups, 431 patients had a virtual follow-up while 1036 of patients required further face to face follow up. 87 patients were triaged into subspecialty clinics. 37 patients were felt to have been referred inappropriately.

Conclusions

BOA guidelines state all patients must be reviewed within 72 hours of their orthopaedic injury. Implementation of a VFC allows this target to be achieved and at the same time reduce patient contact. Almost half the patients were discharged following VFC review, the remaining patients were followed up. This is especially relevant in the current pandemic where reducing unnecessary trips to hospital will benefit the patient and make the most of the resources available.

18 The Rise in Trauma & Orthopaedic Trainee-Led Research and Audit Collaborative Projects in the United Kingdom Since the Start of the COVID-19 Pandemic

Introduction

There has been a significant rise in trainee-led trauma & orthopaedic (T&O) multi-centre research collaborative projects globally. Since the start of the COVID-19 pandemic, more emphasis has been on global collaborative research efforts to tackle important research questions. The aim was to evaluate the number of T&O trainee-led research collaborative projects that took part since the start of the COVID-19 pandemic in the UK.

Method

A retrospective study that evaluated T&O trainee-led national collaborative projects within the UK since the start of the COVID-19 pandemic lockdown (March 2020 to June 2021). Our exclusion criteria included any regional collaborative projects, projects that were started pre-COVID and projects of other surgical specialities. The number of projects identified was compared to that in 2019.

Results

In 2019, 0 trainee-led collaborative projects were commenced nationally in the UK. Since the COVID-19 pandemic, we identified 10 trainee-led collaborative trauma & orthopaedic projects with 3 being published so far. The level of evidence ranged between 3 and 4.

Conclusions

Covid has placed significant challenges across healthcare. One positive aspect that has been noted is the increase in multi-centre trainee-led collaborative projects within the UK. Our study highlights the feasibility of a trainee-led high quality collaborative research projects in the UK, emphasising the growing contribution of trainees towards research. Wide-spread availability of new technological tools such as social media and Redcap® facilitates such projects in terms of recruitment and data collection. We would, therefore, recommend expanding this trainee-led collaborative platform across in Europe and Worldwide.

511 Organising A Surgical Conference During The COVID-19 Pandemic – Is It ‘Virtually’ The Same?

Introduction

Surgical conferences are invaluable events for healthcare professionals; they provide opportunities to engage with upcoming scientific discoveries, network professionally with peers as well as expand learning through lectures and workshops. For medical students, conferences provide an opportunity to expand understanding beyond the undergraduate curriculum in an interactive manner. COVID-19 has caused disruption to the organisation and attendance of in-person conferences (IPCs). Virtual conferences (VCs) offer a viable solution, allowing delegates to attend from the comfort of their own homes.

Method

The aim of our study was to evaluate an organised VC and explore the perceived benefits and limitations of VCs compared to IPCs. A virtual one-day trauma & orthopaedics (T&O) conference was organised involving lectures, workshops, poster, and oral presentations. Anonymous questionnaire forms were distributed to delegates following the conference to assess the aims of our paper.

Results

From 106 responses, 96.2% rated the conference as ‘Excellent’ or ‘Good’ with 92.5% stating that it increased their passion for T&O surgery. Based on a five-point Likert scale (5= strongly agree, 1= strongly disagree), mean score of agreement for preferring VCs to IPCs was 3.30(± 1.24). Key advantages of the VC were a lower cost (70.8%) and not having to travel (77.4%), whereas the main limitation was the inability to participate in hands-on workshops (84.9%).

Conclusions

Despite the success of our VC, delegate feedback indicates a mixed response comparing VCs to IPCs. We share our findings to encourage similar events to be organised and for other specialties.

483 A Quality Improvement Project: Novel Electronic Operative Note Templates to Improve the Continuity of Post-Operative Patient Care

Introduction

Good Surgical Practice from RCS England encourages the use of e-health records and detailed typed operative notes. The Covid-19 pandemic has led to multi-site operating. ENT operations in our trust were split over three sites including the private sector leading to potential disruption in continuity of patient care. Physical operation notes are difficult to access in emergencies, telephonic clinics or for audit purposes. We aim to have operative notes available on patients’ e-records which adhere to RCSEng guidelines.

Method

In this QIP, we reviewed all ENT operations over a retrospective one-month period recording percentage of notes uploaded to patient e-record and the number of surgeons in theatre. We created two novel RCSEng compliant e-operative notes with a user guide, generic and tonsillectomy-specific, and prospectively collected data to complete the cycle.

Results

261 patients were included in both study periods. Only 36/134(27%) had e-operative pre-intervention improving to 71/127(56%) post-intervention. In the latter period, 76% of operations included a registrar and were more likely to have e-operative notes(72%) compared to when a consultant was operating alone(6%). There was low uptake of our tonsillectomy e-proforma(33%).

Conclusions

Our QIP has already proved effective with our templates increasing operative documentation on e-records. Increased use of e-template was more likely with the presence of a registrar in theatre. Room for improvement remains and we will re-audit after the introduction of further user-friendly operative templates and IT training. This QIP has also revealed additional operative training opportunities of which registrars can take advantage.

1434 An Audit of Surgical Consent Standards in Patients Undergoing Elective ENT Surgery

Aim

Good Surgical Practice (RCS England) and GMC guidelines inform a surgeon’s practice in the consent process for an operation. Since the Covid-19 pandemic, many surgical departments have converted from face-to-face to telephonic consultations. The clinic letter is of increased importance given that it forms a key part of the medical record which the patient should receive to ensure sufficient time and information to make an informed decision.

Method

Clinic letters of patients undergoing elective ENT surgery at our trust over a four-week period were examined in this retrospective audit of compliance with RCSEng and GMC guidelines. Additional data was collected on clinician grade and proportion of letters sent to patients. Patients rated satisfaction with consultation on a five-point Likert scale.

Results

135 eligible patients were included in our audit and the majority were listed by a consultant (57%). In all domains, consultant letters were more likely to be comprehensive as compared to registrars. Overall quality of clinic letters was highly variable regarding documentation of diagnosis (52%), surgical risks (50%), discussion of alternative or no treatment (30%) and registrar discussion with consultant (31%). There was also a stark difference between registrars and consultants sending patients copies of clinic letters (10% vs 47%). Only 10% of patients received a leaflet on their condition. 90% of patients were either satisfied or very satisfied with their clinic consultation.

Conclusions

Refresher sessions on consent, updated template letters and increased provision of patient information leaflets will be introduced to the ENT department, and improvements monitored with further re-audit.

771 Shaping the Virtual Learning Environment: Emojis As A Novel Feedback Modality for Content Delivery in Postgraduate Medical Education

Introduction

Postgraduate medical education in the wake of a pandemic has sparked creativity, evolving novel platforms concordant with socially distanced learning. Inevitably, evaluation is critical in navigating improvements in content delivery. However, as culture continues to shift away from didactic teaching, students are at risk of ‘feedback overload’. We propose a novel emoji scale to facilitate rapid appraisal.

Method

A three-point emoji scale was developed within the novel virtual learning environment for core surgical training in the West Midlands. Engagement with the emoji system was assessed and correlated with conventional post-course questionnaires.

Results

The novel emoji system provided a rapid mechanism for trainees to express opinion on individual modules immediately following completion. Parallels to social media meant this modality felt familiar to trainees. Simplification of feedback permitted prompt, targeted review of modules for improvement, as opposed to laborious collection and analysis of standard post-course questionnaires. Literature review revealed limited research regarding similar emoji-based responses, or the validity of Likert or free-text based feedback systems.

Conclusion

As virtual learning evolves following COVID-19, feedback systems help guide evolution. Emoji-based feedback may provide the key to prompt, accessible evaluation of VLE platforms.

Dysregulation of circulating miRNAs promotes the pathogenesis of diabetes-induced cardiomyopathy

Diabetic Cardiomyopathy (DCM) is characterized by myocardial dysfunction caused by diabetes mellitus. After-effects of diabetic cardiomyopathy are far more lethal than non-diabetic cardiomyopathy. More than 300 million people suffer from diabetes and cardiovascular disorder which is expected to be elevated to an alarming figure of 450 million by 2030. Recent studies suggested that miRNA plays important role in the onset of diabetic cardiomyopathy. This study was designed to identify the miRNA that is responsible for the onset of diabetic cardiomyopathy using in silico and in vitro approaches. In this study, to identify the miRNA responsible for the onset of diabetic cardiomyopathy, in silico analysis was done to predict the role of these circulating miRNAs in type 2 diabetic cardiomyopathy. Shared miRNAs that are present in both diseases were selected for further analysis. Total RNA and miRNA were extracted from blood samples taken from type 2 diabetic patients as well as healthy controls to analyze the expression of important genes like AKT, VEGF, IGF, FGF1, ANGPT2 using Real-time PCR. The expression of ANGPT2 was up-regulated and AKT, VEGF, IGF, FGF1 were down-regulated in DCM patients as compared to healthy controls. The miRNA expression of miR-17 was up-regulated and miR-24, miR-150, miR-199a, miR-214, and miR-320a were down-regulated in the DCM patients as compared to healthy controls. This shows that dysregulation of target genes and miRNA may contribute towards the pathogenesis of DCM and more studies should be conducted to elucidate the role of circulating miRNAs to use them as therapeutic and diagnostic options.

Stem cells based in vitro models: trends and prospects in biomaterials cytotoxicity studies

Advanced biomaterials are increasingly used for numerous medical applications from the delivery of cancer-targeted therapeutics to the treatment of cardiovascular diseases. The issues of foreign body reactions induced by biomaterials must be controlled for preventing treatment failure. Therefore, it is important to assess the biocompatibility and cytotoxicity of biomaterials on cell culture systems before proceeding to in vivo studies in animal models and subsequent clinical trials. Direct use of biomaterials on animals create technical challenges and ethical issues and therefore, the use of non-animal models such as stem cell cultures could be useful for determination of their safety. However, failure to recapitulate the complex in vivo microenvironment have largely restricted stem cell cultures for testing the cytotoxicity of biomaterials. Nevertheless, properties of stem cells such as their self-renewal and ability to differentiate into various cell lineages make them an ideal candidate for in vitro screening studies. Furthermore, the application of stem cells in biomaterials screening studies may overcome the challenges associated with the inability to develop a complex heterogeneous tissue using primary cells. Currently, embryonic stem cells, adult stem cells, and induced pluripotent stem cells are being used as in vitro preliminary biomaterials testing models with demonstrated advantages over mature primary cell or cell line based in vitro models. This review discusses the status and future directions of in vitro stem cell-based cultures and their derivatives such as spheroids and organoids for the screening of their safety before their application to animal models and human in translational research.

Understanding the Trends and Variability in Procedures Performed During Orthopedic Spine Surgery Fellowship Training: An Analysis of ACGME Case Log Data

OBJECTIVE

To understand trends and variability of procedures performed by orthopedic spine surgery fellows during training.

DESIGN

Cross-sectional survey.

SETTING

Accreditation Council on Graduate Medical Education (ACGME) case logs.

PARTICIPANTS

Fellows enrolled in ACGME-accredited "Orthopaedic Surgery of the Spine" fellowships from 2010 to 2015.

RESULTS

The 2010 to 2015 ACGME fellowship case logs for "Orthopaedic Surgery of the Spine" were retrieved. Spine cases in case logs are grouped into the following categories: (1) Excision, (2) Osteotomy, (3) Fracture and/or Dislocation, (4) Decompression, (5) Anterior fusion/arthrodesis, (6) Posterior fusion, (7) Deformity surgery, (8) Exploration, (9) Instrumentation, and (10) other/uncategorized. The total number of spine cases logged by each fellow increased from 821 in 2010 to 1134 in 2015 (38.2% increase). The greatest increases were noted from fracture/dislocation cases (77.9%), followed by posterior fusions (62.2%), anterior fusions (43.6%), decompressions (36.3%), and instrumentation (29.5%). The average number of deformity cases decreased from 23 in 2010 to 19 in 2016 (18.6% decrease). The average number of adult-only cases increased from 770 in 2010 to 1100 in 2015 (42.8% increase), whereas the average number of pediatric-only cases declined from 51 in 2010 to 35 in 2015 (32.1% decrease). Based on case logs from 2015, the greatest variation in case volume between the 10th centile and 90th centile of fellows was noted for deformity cases, followed by decompressions and posterior fusions.

CONCLUSIONS

Even though there has been a 38% increase in the overall number of spine cases performed by fellows during training, a large amount of variation in type of case exposure exists between fellowships. The findings of our study call for the establishment of minimal case volumes and/or uniformity of training spectrums across the nation to ensure appropriate surgical care is made accessible to all patients.

Mesenchymal Stem Cells: From Regeneration to Drug Delivery Systems

Targeting drug delivery has been a focus of researchers in recent years for cancer and other diseases. Many approaches such as liposomes, exosomes, nanoparticles (magnetic), encapsulation etc. have been developed and investigated for their clinical applications. But disadvantages linked to these therapies limit them to be used in clinical settings. Cell based drug delivery systems has emerged as an alternative for these therapies. Among cell types, mesenchymal stem cells (MSCs) proved to a potential cell type for research due to its many characteristics including low immunogenicity, chemotaxis and homing to tumor sites which are considered mandatory for drug delivery. This chapter focuses on the challenges and opportunities in using MSCs as therapeutic carrier of drugs in different ailments.

Pathogenesis of Diabetic Cardiomyopathy and Role of miRNA

Diabetic cardiomyopathy is characterized as abnormal function and structure of myocardium associated with diabetes irrespective of other cardiac risk factors like hypertension or coronary artery disease (CAD). The pathogenesis of DCM was not well understood in the past due to its complexity but it has been discovered recently. Various factors are found to be associated with the onset of DCM including impaired calcium handling, remodeling of extracellular matrix (ECM), increased oxidative stress, altered metabolism, mitochondrial dysfunction, and endothelial dysfunction. Micro-RNAs (miRNAs) are also found to be of great importance in the pathogenesis of DCM. Different miRNAs like miR-126, miR-24, miR-1, miR-155, miR-499, and miR-199a are found to be associated with different types of heart diseases like CAD and myocardial infarction. Studies have shown that the miRNA plays a crucial role in the development of DCM and it was found that the expression levels of different miRNAs differ in patients as compared to healthy individuals. This review focuses on the pathogenesis of DCM and various factors involved in the onset of diabetic car-diomyopathy. Moreover, the probable role of miRNA in the pathogenesis of DCM is also discussed.

Improving transfer from secondary to primary care: An audit of discharge letters from psychiatric outpatient clinic

Aims

The discharge letter plays a crucial role in continuity of care from secondary to primary care. We found no existing study of outpatient discharge letters, including Mental Retardation services. New Ways of Working for psychiatrists has encouraged the discharge of stable outpatients to primary care in order to provide a responsive, flexible service. This study set standards for discharge communication and identified areas for improvement.

Methodology

This was a retrospective random audit of 30 service users discharged from a psychiatric outpatient clinic. Standards were set with consultant psychiatrists and general practioners. Data was collected from the service users’ last two clinic letters using a pre-developed audit tool and compared the current practice with the standards identified.

Results

Standards for status and future planning were largely achieved with reference to current mental state (97%), current medication (90%), other LD professionals involved (95%), advice and how to re-refer (90%).Standards for historical factors were partially achieved; including summary of contact with services (70%), summary (57%) and evaluation (67%) of treatments received. Some standards were not achieved; including requesting view of primary care prior to discharge (27%), statement of capacity (23%), risk factors (23%) and relapse indicators (27%).

Conclusion

The audit showed areas of good practice and areas for improvement. Results were disseminated to MDT's and a template developed for outpatient discharge letters. A re-audit has commenced to ensure progress in this important information-sharing process and to enhance the delivery of safe and effective health care.

Lipid monitoring of patients taking clozapine in a high secure forensic hospital

Aims

To review current practice of lipid monitoring for patients prescribed colzapine and to improve the health of patients taking clozapine.

Methodology

This was a retrospective audit targeting all patients who were taking Clozapine from May 2008 to April 2009 inclusive. Data was collected from pharmacy records, the heath centre records and patients’ personal care records. Current practice within the hospital was then compared with the standards proposed by the Maudsley Guidelines.

Results

The total number of patients who were prescribed clozapine between May 2008 to April 2009 was 65. Of these patients 54 met the identified standards. We identified two patient groups; 56 patients were taking clozpaine for more than one year and nine patients were taking clozapine for less than one year. Out of those patients who were taking clozapine for more than one year, standards were met for 89% of patient (n = 50) compared to only 44% (n = 9) of those patients who were taking it for less than 1 year. Also, of those patients who had been taking clozapine for less than one year and do not meet the standard, none of them had lipid monitoring at three monthly intervals.

Conclusion

Although the vast majority of patients in the hospital who were prescribed Clozapine had their lipids monitored appropriately, a small percentage did not. Monitoring of lipid levels was particularly lacking in the first year of treatment.

Computational screening of phytochemicals against survivin protein: A potent target for cancer

Survivin (IAP proteins) is considered as a significant target for anticancer drug research owing to its upregulation in tumor cells to mediate resistance to apoptotic stimulus. The current study aimed to investigate phytochemicals as inhibitors of survivin with caspases to reactivate the functioning of caspases through molecular docking. The compounds namely 2(R), 4(R)-dihydroxypyrrolidine, 4-hydroxy-2-(4-methoxyphenyl)-1,1-dioxo-3,4-dihydrothieno[3,2-e]thiazine-6-sulfonamide, 2,3-Diketo-L-gulonic acid, (3-hydroxy-2-octadeca-9,12-dienoyloxypropyl) octadecanoate, 2-[[4-[[4-[(4-formamido-1-methylimidazole-2-carbonyl)amino]-1-methylimidazole-2-carbonyl]amino]-1-methylimidazole-2-carbonyl]amino]ethyl-dimethylazanium, Picolinic acid and (2-Hydroxy-5-nitrophenyl) dihydrogen phosphate successfully bind inside the pocket of survivin. ADMETsar was used to evaluate the anticancer potential of selected compounds. These compounds can be proposed as effective inhibitors, disrupting the survivin-caspases interaction and reactivating the caspases function of apoptosis. The study might facilitate the development of cost-effective and natural drugs against cancer. However, further validation is essential for confirmation of its drug efficacy and bio-compatibility.

Risperidone for psychosis-induced aggression or agitation (rapid tranquillisation)

BACKGROUND

Aggressive, agitated or violent behaviour due to psychosis constitutes an emergency psychiatric treatment where fast-acting interventions are required. Risperidone is a widely accessible antipsychotic that can be used to manage psychosis-induced aggression or agitation.

OBJECTIVES

To examine whether oral risperidone alone is an effective treatment for psychosis-induced aggression or agitation.

SEARCH METHODS

We searched the Cochrane Schizophrenia Group's Study-Based Register of Trials (up to April 2017); this register is compiled by systematic searches of major resources (including AMED, BIOSIS CINAHL, Embase, MEDLINE, PsycINFO, PubMed, and registries of clinical trials) and their monthly updates, handsearches, grey literature, and conference proceedings. There are no language, date, document type, or publication status limitations for inclusion of records into the register.

SELECTION CRITERIA

Randomised controlled trials (RCTs) comparing rapid use of risperidone and other drugs, combinations of drugs or placebo for people exhibiting aggression or agitation (or both) thought to be due to psychosis.

DATA COLLECTION AND ANALYSIS

We independently inspected all citations from searches, identified relevant abstracts, and independently extracted data from all included studies. For binary data we calculated risk ratio (RR) and for continuous data we calculated mean difference (MD), all with 95% confidence intervals (CI) and used a fixed-effect model. We assessed risk of bias for the included studies and used the GRADE approach to produce a 'Summary of findings' tables.

MAIN RESULTS

The review now contains data from nine trials (total n = 582) reporting on five comparisons. Due to risk of bias, small size of trials, indirectness of outcome measures and a paucity of investigated and reported 'pragmatic' outcomes, evidence was graded as very-low quality. None of the included studies provided useable data on our primary outcome 'tranquillisation or asleep' by 30 minutes, repeated need for tranquillisation or any economic outcomes. Data were available for our other main outcomes of agitation or aggression, needing restraint, and incidence of adverse effects.Risperidone versus haloperidol (up to 24 hours follow-up)For the outcome, specific behaviour - agitation, no clear difference was found between risperidone and haloperidol in terms of efficacy, measured as at least 50% reduction in the Positive and Negative Syndrome Scale - Psychotic Agitation Sub-score (PANSS-PAS) (RR 1.04, 95% CI 0.86 to 1.26; participants = 124; studies = 1; very low-quality evidence) and no effect was observed for need to use restraints (RR 2.00, 95% CI 0.43 to 9.21; participants = 28; studies = 1; very low-quality evidence). Incidence of adverse effects was similar between treatment groups (RR 0.94, 95% CI 0.54 to 1.66; participants = 124; studies = 1; very low-quality evidence).Risperidone versus olanzapineOne small trial (n = 29) reported useable data for the comparison risperidone versus olanzapine. No effect was observed for agitation measured as PANSS-PAS endpoint score at two hours (MD 2.50, 95% CI -2.46 to 7.46; very low-quality evidence); need to use restraints at four days (RR 1.43, 95% CI 0.39 to 5.28; very-low quality evidence); specific movement disorders measured as Behavioural Activity Rating Scale (BARS) endpoint score at four days (MD 0.20, 95% CI -0.43 to 0.83; very low-quality evidence).Risperidone versus quetiapineOne trial reported (n = 40) useable data for the comparison risperidone versus quetiapine. Aggression was measured using the Modified Overt Aggression Scale (MOAS) endpoint score at two weeks. A clear difference, favouring quetiapine was observed (MD 1.80, 95% CI 0.20 to 3.40; very-low quality evidence). No evidence of a difference between treatment groups could be observed for incidence of akathisia after 24 hours (RR 1.67, 95% CI 0.46 to 6.06; very low-quality evidence). Two participants allocated to risperidone and one allocated to quetiapine experienced myocardial ischaemia during the trial.Risperidone versus risperidone + oxcarbazepineOne trial (n = 68) measured agitation using the Positive and Negative Syndrome Scale - Excited Component.(PANSS-EC) endpoint score and found a clear difference, favouring the combination treatment at one week (MD 2.70, 95% CI 0.42 to 4.98; very low-quality evidence), but no effect was observed for global state using Clinical Global Impression - Improvement (CGI-I) endpoint score at one week (MD -0.20, 95% CI -0.61 to 0.21; very-low quality evidence). Incidence of extrapyramidal symptoms after 24 hours was similar between treatment groups (RR 1.59, 95% CI 0.49 to 5.14; very-low quality evidence).Risperidone versus risperidone + valproic acidTwo trials compared risperidone with a combination of risperidone plus valproic acid. No clear differences between the treatment groups were observed for aggression (MOAS endpoint score at three days: MD 1.07, 95% CI -0.20 to 2.34; participants = 54; studies = 1; very low-quality evidence) or incidence of akathisia after 24 hours: RR 0.75, 95% CI 0.28 to 2.03; participants = 122; studies = 2; very low-quality evidence).

AUTHORS' CONCLUSIONS

Overall, results for the main outcomes show no real effect for risperidone. The only data available for use in this review are from nine under-sampled trials and the evidence available is of very low quality. This casts uncertainty on the role of risperidone in rapid tranquillisation for people with psychosis-induced aggression. High-quality pragmatic RCTs are feasible and are needed before clear recommendations can be drawn on the use of risperidone for psychosis-induced aggression or agitation.

Cerebral Microbleeds are an Independent Predictor of Hemorrhagic Transformation Following Intravenous Alteplase Administration in Acute Ischemic Stroke

BACKGROUND AND PURPOSE

Intravenous alteplase (rt-PA) increases the risk of hemorrhagic transformation of acute ischemic stroke. The objective of our study was to evaluate clinical, laboratory, and imaging predictors on forecasting the risk of hemorrhagic transformation following treatment with rt-PA. We also evaluated the factors associated with cerebral microbleeds that increase the risk of hemorrhagic transformation.

METHODS

Consecutive patients with acute ischemic stroke admitted between January 1, 2009 and December 31, 2013 were included in the study if they received IV rt-PA, had magnetic resonance imaging (MRI) of the brain on admission, and computed tomography or MRI of the brain at 24 (18-36) hours later to evaluate for the presence of hemorrhagic transformation. The clinical data, lipid levels, platelet count, MRI, and computed tomography images were retrospectively reviewed.

RESULTS

The study included 366 patients, with mean age 67 ± 15 years; 46% were women and 88% were white. The median National Institutes of Health Stroke Scale (NIHSS) score was 6 (interquartile range 3-15). Hemorrhagic transformation was observed in 87 (23.8%) patients and cerebral microbleeds were noted in 95 (25.9%). Patients with hemorrhagic transformation tended to be older, nonwhite, have atrial fibrillation, higher baseline NIHSS score, lower cholesterol and triglyceride levels, and cerebral microbleeds and nonlacunar infarcts. Patients with cerebral microbleeds were more likely to be older, have hypertension, hyperlipidemia, previous history of stroke, and prior use of antithrombotics. On multivariate analysis race, NIHSS score, nonlacunar infarct, and presence of cerebral microbleeds were independently associated with hemorrhagic transformation following treatment with rt-PA.

CONCLUSIONS

Presence of cerebral microbleeds is an independent predictor of hemorrhagic transformation of acute ischemic stroke following treatment with rt-PA.

Abstract WP59: A Clot Burden Score Predicts Functional Outcome and Neurological Complications After Cerebral Venous Sinus Thrombosis

Background and purpose: Involvement of deep venous structures is associated with worse outcomes in patients with cerebral venous sinus thrombosis (CVST); however, the impact of clot burden has not been studied. The aim of this study was to assess the value of a novel quantitative clot burden score as an independent predictor of clinical outcomes.

Methods: We retrospectively reviewed all patients admitted to University of Iowa Health Care with CVST between 2004-2014. All patients received standard of care medical management per AHA/ASA recommendations. The degree of the thrombosis was categorized in admission MR venograms as (partial=1 vs. complete occlusion=2). Clot burden scores were computed as the sum of the thrombosis degree in the following vessels: cerebral veins (cortical veins, internal cerebral, vein of Rosenthal, vein of Galen) and cerebral sinuses (superior sagittal, inferior sagittal, straight, torcula, transverse/sigmoid). The primary outcome was modified Rankin Scale (mRS) at discharge. Secondary outcomes included hemorrhage, infarction, and cerebral edema. Multiple regressions were conducted to examine effects of clot burden scores on each of the four outcomes.

Results: 115 patients met inclusion criteria, 76 women, and mean age 42. Thrombosis in cerebral veins area was noted in 58(50%), clot burden score Median=4, IQR=2; while 108(96%) had thrombosis in the cerebral sinuses area, Median=4, IQR=5. Clot burden in cerebral veins (p=.005) but not in cerebral sinuses, was associated with worse discharge mRS, r= .22. This effect remained significant when adjusting for age and gender (p=.002), but not when adjusting for complications including ICH, infarct, edema. Importantly, higher clot burden score in the cerebral veins predicted ICH (OR=1.73, p<.001), infarct size (OR=1.66, p<.001), and edema (OR=1.71, p<.001).

Conclusion: Quantitative clot burden measurement of the cerebral veins conveys additional prediction on outcomes of CVST. Our findings suggest that the worse clinical outcomes associated with clot burden in the cerebral veins may be mediated by ICH, infarct size, and/or edema. The structural differences between the cerebral veins and sinuses may play a role in the variability in clinical outcomes among patients with CVST.

Abstract TMP18: Heparin Resistance is an Independent Predictor of Poor outcome in Cerebral Venous Sinus Thrombosis

Background and purpose: Unfractionated Heparin (UFH) infusion represents the most commonly used therapy in the acute management of cerebral venous sinus thrombosis (CVST). effectiveness of heparin in reaching therapeutic anti-coagulation levels has not been well studied in this population. Identifying subgroup of patients who will not respond to Heparin may prove useful in studying alternative treatments such as the new oral anticoagulants and endovascular therapy. We aimed to evaluate the initial response to heparin infusion measured by partial thromboplastin time (PTT) and it implication in discharge outcome.

Methods: Retrospective review of all consecutive patients at University of Iowa Hospitals and Clinics between 2004-2014 with CVST was conducted. All patients were treated with initial weight based bolus (14units/kg) of UFH followed by infusion. Consecutive PTT values in the first 48hrs of admission were classified as either therapeutic (40-87), supra-therapeutic (>87), or resistant (<40). Then patients were classified as good responders if 80% of PTT values were in the therapeutic range, classified as adequate if 65-79% of PTT values were therapeutic; rest of patients were classified as non-responders. Univariate and multivariate regressions models were performed to assess the association with discharge mRS, the primary outcome.

Results: 115 patients met inclusion criteria (76 women), mean age was 42. Mean PTT was 44.8 (SD=18.6; 95%CI of 41.2-48.5) in the first 48 hours. Patients resistant to Heparin (44%) had significantly worse functional outcomes, mRS [95%CI 2.3-3.6], compared to good [41%, 95%CI 1.2-2.3] and adequate responders to Heparin [15%, 95%CI 0.5-2.3] (p=.003). Mean PTT in the first 48 hours predicted discharge mRS, r=-.28,p<.005 and this effect remained significant when age, sex, altered mental status at admission were controlled, p=.001.

Conclusion: A significant portion of patients that receive heparin do not reach therapeutic levels within the initial days after hospitalization, and this does not appear to be a consequence of disease burden in our population. Specifying clinical features that predict heparin resistance might help to identify patients that benefit from alternative anticoagulation therapies.

Abstract WP47: Quantitative Analysis of Hemorrhage and Infarct Volume for Predicting Outcome in Cerebral Venous Sinus Thrombosis

Background and purpose: Intracerebral hemorrhage (ICH) and venous infarction are known complications that independently predict poor outcome in patients with cerebral venous sinus thrombosis (CVST). We aimed to study the utility of precise quantification of volumes of venous infarction and ICH using digitalized images in refining our prediction of discharge outcome.

Methods: We retrospectively reviewed all patients with CVST admitted to University of Iowa Health Care between 2004-2014. All patients received standard of care management per available AHA/ASA recommendations. Scans were analyzed using Carestream Vue PACS software. Gradient Echo (GRE) MRI sequence was used to calculate ICH volume. When MRI was not available CT was used. Diffusion Weighted Imaging (DWI) MRI sequence was used to calculate infarction volume. Volume scorer was blinded to the clinical outcomes. Univariate and multivariate analyses were conducted. A p value ≤ 0.05 was set as statistically significant.

Results: 115 patients met inclusion criteria, 76 women, mean age 42. A total of 30 (26%) had venous infarction, 34 (30%) had ICH. The median volumes were 8 cc (SD=27) for ICH and 14 cc (SD= 35) for infarction. Both ICH and infarction volumes were significantly higher among those with a poor functional outcome (mRS=3-6) [Mdn=16 cc, SD=32 for ICH; Mdn=33 cc, SD=46 for infarction] than those with good outcome [Mdn=5 cc, SD=7 for ICH; Mdn=7 cc, SD=162 for infarction], p= .029 and p=.027 respectively. The correlation between ICH volume and mRS was r=.43, p=.012 and the corresponding correlation for infarction volume was r=.62, p=.002. Regressions testing the effects of ICH and infarction volumes on discharge mRS showed that both significantly contributed (p<.001 & p=.004 respectively). These effects remained significant when controlling for the effects of age, gender, presence of deep infarct, and altered mental status at presentation (p=.001 and p=.013 respectively).

Conclusion: Quantitative measurement of Infarction and ICH volumes on admission leads to a more accurate prediction of outcome at discharge in CVST patients. Its combination with clinical variables might signify an additional prognostication tool for identification of high risk patients refractory to standard therapy.

Abstract WP63: Global Cerebral Edema is Associated With Worse Outcomes in Patients With Cerebral Venous Sinus Thrombosis

Background and Purpose: Obstruction of venous drainage may lead to venous hypertension, edema, infarction or intracerebral hemorrhage (ICH) in patients with cerebral venous thrombosis (CVST). While the presence of ICH and infarction are associated with worse outcomes, the independent effect of edema remains unknown. We aimed to evaluate the impact of the characteristics of brain edema on functional outcomes as measured by the modified Rankin Scale (mRS) at discharge.

Methods: We retrospectively reviewed all patients who presented to the University of Iowa Health Care with CVST between 2004-2014. All patients received standard of care management per available AHA/ASA recommendations. Edema was categorized as focal vasogenic, focal cytotoxic or global cerebral edema (GCE). Vasogenic edema was described as hyperintensity on FLAIR MRI sequences around the location of venous clot while cytotoxic edema was noted when hyperintensities were visualized around the location of ICH/ venous infarction on FLAIR or DWI respectively. GCE was scored when bilateral finger-like extensions into gray white junction and effacement of gyri/sulci were seen on CT scans as described by Claassen et al. Edema scorer was blinded to outcome measures. Multiple regressions were conducted on mRS outcome to test hypotheses of interest. A p value ≤ 0.05 was set as statistically significant.

Results: 115 patients met inclusion criteria, 76 women, mean age 42. A total of 30(26%) had venous infarction, 34(30%)ICH , 57(50%) had cerebral edema(20% vasogenic, 35% cytotoxic and 32% GCE). The three edema types together explained 22% variance in discharge mRS (p<.001). The effect of GCE remained significant (p=.001) when adjusting for age, presence/absence of ICH and infarct. The 95%CIs for discharge mRS among those with GCE [2.89-4.17] compared to those without GCE [1.44-2.12]. Vasogenic and cytotoxic edema did not contribute significantly to prediction in multivariate analyses.

Conclusions: Characterization of early cerebral edema might contribute to a better prognostication of high risk patients after CVTS. GCE in particular forecast an unfavorable outcome. Further understanding of its pathogenesis may represent a new therapeutic window for refractory patients to standard therapies.

The representation of low- and middle-income countries in the psychiatric research literature

Despite the growing importance of mental health in international and national policies, the contribution to the psychiatric evidence base from non-Western countries is sparse. Such a gap in research output between high- and low-income countries constrains improvements in public health and mental health policy and practice in developing countries, where there is perhaps the greatest unmet need. If research is to inform local mental health policy and practice, it must reflect the diverse realities of local health systems and cultural factors.

Improving oral health care in mental health service – A retrospective study of oral health care monitoring for service users accessing community mental health team

Introduction

Poor oral health can have a serious impact on quality of life, social inclusion and self-esteem. There is evidence to suggest that people with serious mental illness have a greater risk of experiencing oral disease and have greater oral treatment needs than the general population. Oral health problems are not well recognized by mental health professionals. We therefore conducted a retrospective study to review oral health care monitoring within the community mental health team.

Aims and objectives

To review the oral health care monitoring for patients accessing the community mental health team.

Methodology

Audit tool was developed based on oral health care guidelines outlined by the department of health, and literature review. We then retrospectively review medical records of 25 patients against following standards:.

– every client should have the most basic of oral hygiene equipment–toothbrush;

– clients should have basic oral hygiene knowledge, (i.e. brush twice or at least once a day);

– every client should be registered to a dental practitioner;

– every client should have at least one dental check-up per year;

– clients with dentures should have their dentures checked up at least once in five years;

– have a tooth brush less than three months old.

Results

Out of the 25 patients none had met the standards. It could be a reflection of lack of documentation rather than not providing appropriate information.

Conclusion

Oral health care advice should be part of care plan for people accessing mental health service.

Disclosure of interest

The authors have not supplied their declaration of competing interest.

Abstract WP52: White Matter Hyperintensity, Cerebral Microbleeds and Risk of Hemorrhagic Transformation with Intravenous rt-PA

Background and Purpose: Intravenous rt-PA is associated with risk of hemorrhagic transformation. We sought to determine if the degree of white matter hyperintensity on Fluid Attenuated Inversion Recovery (FLAIR) and the presence of cerebral microbleeds (MB) on Gradient Recalled Echo (GRE) sequences on MRI was associated with increased risk of hemorrhagic transformation following intravenous rt-PA.

Methods: Acute ischemic stroke patients admitted to University of Iowa Hospitals and Clinics between 1/1/2009 and 12/31/2013 were included in the study if - i) received intravenous rt-PA ii) had MRI brain with Diffusion Weighted Imaging (DWI), GRE and FLAIR sequence within the first 48 hours of stroke onset, and iii) had CT head or MRI at 20-36hr post rt-PA to evaluate for hemorrhagic transformation. White matter hyperintensity on FLAIR was evaluated based on Fazekas scale from 0-4. A score of 0 and 1 on Fazekas scale was combined to form group 1 and a score 3 and 4 was combined to form group 2 for analysis. MB were evaluated on GRE. Presence of MB was categorized as group 1 (1-5 MB) and 2 (6 or more MB). CT or MRI head performed at 20-36 hours after rt-PA was evaluated for hemorrhagic transformation. If present it was classified as group 1 (HI 1 and 2) and 2 (PH 1 and 2).

Results: A total of 402 patients met the study criteria among 607 patients. Mean age was 67±14 years. Among them 45% were women and 88% whites. FLAIR deep white matter hyperintensity was graded on Fazekas as 0 - 26%, 1-51%, 2-12% and 3-11%. FLAIR periventricular white matter hyperintensity was graded as 0 - 10%, 1-49%, 2-25% and 3- 16%. MB were present in 26% of the study population with only 3 patients in group 2. Hemorrhagic transformation was seen in 24% of the patients with 66% of these having petechial hemorrhage. Deep white matter (p=0.47) and periventricular (p=0.73) white matter hyperintensity was not significantly associated with hemorrhagic transformation. However, presence of MB was significantly associated with hemorrhagic transformation (p=0.006, OR = 2.03, CI 1.215-3.392).

Conclusion: Microbleeds increases the risk of hemorrhagic transformation following administration of intravenous rt-PA. However, white matter hyperintensity did not result in increased risk of hemorrhagic transformation after rt-PA.

Self injection of foreign materials into the penis

Injection of the subcutaneous tissues of the penis for enlargement of penile girth has been practised for many years by laypeople and medical practitioners alike. However, with recognition of the complications, the practice has died out. We report a series of five patients who presented having injected foreign materials into the subcutaneous tissues of their penises, including paraffin and mineral oils. Our patients had a variable time course of presentation ranging from 1 day following injection to over 26 years. Self-injection of the subcutaneous tissues of the penis is an unusual presentation for a penile mass but should be considered as a differential diagnosis in patients with a long latent period to presentation or with characteristic magnetic resonance imaging and histological appearances.

Canadian Registry of LVIS Jr for Treatment of Intracranial Aneurysms (CaRLA)

INTRODUCTION

Stents reduce the rate of angiographic recurrence of intracranial aneurysms. The newest stent for intracranial use is the Low-profile Visible Intraluminal Support device (LVIS Jr).

OBJECTIVE

To assess the efficacy of the new stent in a multicenter retrospective registry.

MATERIALS AND METHOD

Centers across Canada using LVIS Jr were contacted and asked to participate in a retrospective registry of consecutive patients treated with LVIS Jr for intracranial aneurysms between January 2013 and July 2015.

RESULTS

A total of 102 patients, with saccular aneurysms in 100 patients (72 women; age range 21-78 years; mean 56.0 years; median 57.5 years) were treated with a LVIS Jr stent. The mean maximum diameter of the dome and neck of the aneurysm and dome to neck ratios were 8.3 mm±7.7 mm, 4.4 mm±1.9 mm, and 1.86±1.22, respectively. Angiographic complications arose in 23 patients, clinical complications in 9 patients, and only 3% of permanent neurological deficits occurred. Death occurred in 1 patient, unrelated to the stent. The ruptured status of the aneurysms (OR=3.29; p=0.046) and use of LVIS Jr for bailout (OR=2.54; p=0.053) showed a trend towards significant association with higher angiographic complications. At the last available follow-up, 68 class I, 20 class II, and 12 class III results were seen.

CONCLUSIONS

The LVIS Jr stent is a safe and effective device for stent-assisted coiling, with 3% permanent neurological complications. Stent-assisted coiling continues to be technically challenging in cases of ruptured aneurysms and bailout situations.

An ovary as unusual contents of an incarcerated umbilical hernia

We present the unusual case of a woman presenting with an incarcerated umbilical hernia. Intraoperatively, the contents of the hernia were found to be an ovary. We outline the clinical presentation of our patient, investigations and management as well as a discussion on unusual contents of umbilical hernias. To our knowledge, this is the first case of a non-malignant ovary incarcerated in an umbilical hernia.

Treatment of hepatitis C virus infection in patients on maintenance hemodialysis: a single United Arab Emirates center experience

BACKGROUND

Hepatitis C is prevalent among hemodialysis patients. In patients with normal kidney function, treatment with pegylated interferon and ribavirin can lead to eradication of HCV (hepatitis C virus). But the treatment is more problematic in patients with impaired kidney function, in part due to the altered pharmacokinetics of these medications. Despite recent guidelines, the optimal strategy in this group of patients is not well defined.

METHOD

In a retrospective study, we reviewed all patients with chronic hepatitis C on hemodialysis treated at Sheikh Khalifa Medical City, in the United Arab Emirates between 2003 and 2009. The aim of our study was to determine the rate of sustained viral response (SVR) and to establish the safety and rate of dropouts in the different treatment regimens used (patients treated with peginterferon only and patients treated with peginterferon and low dose ribavirin).

RESULTS

22 patients were treated during this period. 5 patients received monotherapy with a reduced dose of peginterferon alfa 2b s.c. once weekly while 17 patients were treated with a combination of reduced dose of peginterferon alfa 2a or 2b s.c. once weekly and a low dose ribavirin (200mg/day). A SVR was achieved in 73% (16/22 patients) of the total patient population and in 76% (13/17 patients) in the sub-group of patients treated with a combination therapy. The tolerability was high. No patients had to discontinue their treatment. The use of ESA (erythropoietin stimulating agents) and G-CSF was common in the combination therapy (94% and 53% respectively).

CONCLUSION

In our study of patients on hemodialysis with chronic hepatitis C, the use of peginterferon or a combination of peginterferon with a low daily dose of ribavirin achieved a high rate of SVR and the rate of dropout was low after pursuing an aggressive management of side effects.