Development of a reliable surgical quality assurance tool for gastrectomy in oncological trials

BACKGROUND

Despite its recognized importance, there is currently no reliable tool for surgical quality assurance (SQA) of gastrectomy in surgical oncology. The aim of this study was to develop an SQA tool for gastrectomy and to apply this tool within the ADDICT Trial in order to assess the extent and completeness of lymphadenectomy.

METHODS

The operative steps for D1+ and D2 gastrectomy have been previously described in the literature and ADDICT trial manual. Two researchers also performed fieldwork in the UK and Japan to document key operative steps through photographs and semi-structured interviews with expert surgeons. This provided the steps that were used as the framework for the SQA tool. Sixty-two photographic cases from the ADDICT Trial were rated by three independent surgeons. Generalizability (G) theory determined inter-rater reliability. D-studies examined the effect of varying the number of assessors and photographic series they rated. Chi-square assessed intra-rater reliability, comparing how the individual assessor's responses corresponded to their global rating for extent of lymphadenectomy.

RESULTS

The tool comprised 20 items, including 19 anatomical landmarks and a global rating score. Overall reliability had G-coefficient of 0.557. Internal consistency was measured with a Cronbach's alpha score of 0.869 and Chi-square confirmed intra-rater reliability for each assessor as < 0.05.

CONCLUSIONS

A photographic surgical quality assurance tool is presented for gastrectomy. Using this tool, the assessor can reliably determine not only the quality but also the extent of the lymphadenectomy performed based on remaining anatomy rather than the excised specimen.

Fecal Bacteria Contamination of Floodwaters and a Coastal Waterway From Tidally-Driven Stormwater Network Inundation

Inundation of coastal stormwater networks by tides is widespread due to sea-level rise (SLR). The water quality risks posed by tidal water rising up through stormwater infrastructure (pipes and catch basins), out onto roadways, and back out to receiving water bodies is poorly understood but may be substantial given that stormwater networks are a known source of fecal contamination. In this study, we (a) documented temporal variation in concentrations of Enterococcus spp. (ENT), the fecal indicator bacteria standard for marine waters, in a coastal waterway over a 2-month period and more intensively during two perigean spring tide periods, (b) measured ENT concentrations in roadway floodwaters during tidal floods, and (c) explained variation in ENT concentrations as a function of tidal inundation, antecedent rainfall, and stormwater infrastructure using a pipe network inundation model and robust linear mixed effect models. We find that ENT concentrations in the receiving waterway vary as a function of tidal stage and antecedent rainfall, but also site-specific characteristics of the stormwater network that drains to the waterway. Tidal variables significantly explain measured ENT variance in the waterway, however, runoff drove higher ENT concentrations in the receiving waterway. Samples of floodwaters on roadways during both perigean spring tide events were limited, but all samples exceeded the threshold for safe public use of recreational waters. These results indicate that inundation of stormwater networks by tides could pose public health hazards in receiving water bodies and on roadways, which will likely be exacerbated in the future due to continued SLR.

Challenges to genetic testing for germline mutations associated with breast cancer among African Americans Authors

Inequities in preventive cancer screening, diagnosis, treatment, and inferior cancer outcomes continue to pose challenges across the cancer continuum. While the exact reasons for these inferior outcomes are unknown, multiple barriers to various domains of social determinants of health (SDOH) play a vital role, leading to inequities in cancer care. These include barriers to transportation, housing, and food insecurities, contributing to delays in preventive screening and treatment. Furthermore, aggressive biologies also exist across various racial profiles with accompanying germline mutations. For example, African Americans (AAs) have a higher incidence of triple-negative breast cancer subtype and a high prevalence of BRCA1/2 gene mutations, increasing the risk of multiple cancers, warranting high-risk screening for these populations. Unfortunately, other barriers, such as financial insecurities, low health literacy rates, and lack of awareness, lead to delays in cancer screening and genetic testing, even with available high-risk screening and risk reduction procedures. In addition, physicians receive minimal interdisciplinary training to address genetic assessment, interpretation of the results, and almost no additional training in addressing the unique needs of racial minorities, leading to suboptimal delivery of genetic assessment provision resources among AAs. In this review, we discuss the confluence of factors and barriers limiting genetic testing among AAs and highlight the prevalence of germline mutations associated with increased risk of breast cancer among AAs, reflecting the need for multi-panel germline testing as well as education regarding hereditary cancer risks in underserved minorities.

C5aR2 Regulates STING-Mediated Interferon Beta Production in Human Macrophages

The complement system mediates diverse regulatory immunological functions. C5aR2, an enigmatic receptor for anaphylatoxin C5a, has been shown to modulate PRR-dependent pro-inflammatory cytokine secretion in human macrophages. However, the specific downstream targets and underlying molecular mechanisms are less clear. In this study, CRISPR-Cas9 was used to generate macrophage models lacking C5aR2, which were used to probe the role of C5aR2 in the context of PRR stimulation. cGAS and STING-induced IFN-β secretion was significantly increased in C5aR2 KO THP-1 cells and C5aR2-edited primary human monocyte-derived macrophages, and STING and IRF3 expression were increased, albeit not significantly, in C5aR2 KO cell lines implicating C5aR2 as a regulator of the IFN-β response to cGAS-STING pathway activation. Transcriptomic analysis by RNAseq revealed that nucleic acid sensing and antiviral signalling pathways were significantly up-regulated in C5aR2 KO THP-1 cells. Altogether, these data suggest a link between C5aR2 and nucleic acid sensing in human macrophages. With further characterisation, this relationship may yield therapeutic options in interferon-related pathologies.

Unplanned Hospitalization and Subsequent Mortality in Lung Cancer Patients Undergoing Concomitant Chemo-/Immuno-Therapy and Radiotherapy: An Analysis of Over 10,000 Patients in a Nationwide Database

PURPOSE/OBJECTIVE(S)

Radiotherapy (RT) and concomitant chemotherapy (CHT) is a major modality for treating many malignancies including lung cancer and is associated with toxicity-related unplanned hospitalization (UPH). Previous investigations of factors associated with UPH have been single institutional retrospective studies and none assessed the role of concurrent immunotherapy (IO). Here, we aimed to identify factors associated with UPH and in-hospital mortality by leveraging a multi-institutional nationwide database.

MATERIALS/METHODS

The Vizient® Clinical Data Base which includes data from 98% of the AAMC hospitals and 110 cancer hospitals, was queried for lung cancer patients (any histology) treated in 2019-2021 with RT+CHT/IO. Endpoints were UPH and mortality during or within 30 days of completion of RT. The variables included age, sex, race, ethnicity, income level (quartile), an education level (quartile), any concomitant CHT or IO drugs, RT technique (3D vs. IMRT vs. SBRT), obesity, prior hospitalization within 3 months, prior oncologic surgery within 3 months, prior CHT and/or IO within 3 months, insurance types, hospital types (Rural vs. Urban, AAMC vs. non-AAMC, NCCN vs. non-NCCN, bed size tertile). Logistic regression was performed to identify variables associated with UPH and in-hospital mortality. Data from the Vizient Clinical Data Base used with permission of Vizient, Inc. All rights reserved.

RESULTS

A total of 10,337 patients were included. The rate of UPH and mortality among UPH was 24.5% and 3.2%, respectively. Factors associated with UPH included other races (vs. White, OR 1.44; 95% CI 1.11-1.88; p<0.001), living in a low income zip code (OR 1.7; 95% CI 1.39-2.09; p = 0.0006), living in a zip code with lower education attainment (OR 0.71; 95% CI 0.58-0.86; p = 0.0007), CHT/IO types (cis-etoposide vs. carbo-Taxol, OR 1.33; 95% CI 1.13-1.57; p<0.0001), obesity (OR 1.71; 95% CI 1.53-1.92; p<0.0001), prior hospitalization (OR 2.0; 95% CI 1.80-2.22; p<0.0001), prior oncologic surgery (OR 0.34; 95% CI 0.22-0.52; p<0.0001), other primary payers (vs. commercial; OR 1.75; 95% CI 1.37-2.23; p<0.0001), rural hospital (OR 1.3; 95% CI 1.07-1.62, p<0.01), small bed size (OR 0.59; 95% CI 0.5-0.71; p<0.0001). Factors associated with in-hospital mortality included CHT/IO type (p<0.0001, but cis-etoposide vs. carbo-taxol no difference), prior hospitalization (OR 0.34; 95% CI 0.2-0.56; p<0.0001), AAMC (OR 2.12; 95% CI 1.23-3.67; p = 0.007), bed size (OR 0.58; 95% CI 0.38-0.88; p<0.01).

CONCLUSION

In the largest study to date regarding UPH and in-hospital mortality related to lung RT, we identified factors contributing to these endpoints. Future prospective studies are warranted to develop strategies to prevent these complications in high-risk populations.

Sensing and the Shadows: Invisible Work in Medical Education in the Netherlands

Medical schools are important nodes in the reproduction of medical knowledge, and an often-visited field site for medical anthropologists. To date, the spotlight has been on teachers, students and (simulated) patients. I broaden this focus to look at the practices of medical school secretaries, porters and other staff, investigating the embodied effects of their "invisible work." Drawing from ethnographic fieldwork in a Dutch medical school, I mobilize the more multisensory term "shadow work" to understand how such practices become part of medical students' future clinical practices through highlighting, isolating, and exaggerating, necessary elements of their medical education.

Enhancing American Indians'/Alaska Natives' Knowledge, Confidence, and Community During the Medical School Application Process: Findings From the Northwest Native American Center of Excellence

PURPOSE

To describe a Medical School Applicant Workshop (MSAW); present lessons learned about its impact on American Indian/Alaska Native (AIAN) participants' knowledge, confidence, and sense of community; and report on participants' medical school application progress 1 year after workshop completion.

METHOD

The Northwest Native American Center of Excellence at Oregon Health & Science University developed and implemented an annual 1-day AIAN MSAW in 2018. The main objectives of the workshop are for participants to gain insights into the medical school application process; learn strategies to competitively apply; receive feedback on their personal statement and mock interviews; and discuss the medical school application process with AIAN faculty, admissions deans, and peer-mentors. Recruitment of AIAN participants occurred via email; social media; text messaging; medical association contacts; and AIAN and science, technology, engineering, and mathematics organizations. Two surveys were administered: one immediately after and another 1-year after the workshop.

RESULTS

Forty AIAN MSAW participants were accepted in 2018-2020. Findings indicate statistically significant increases in participants' self-reported knowledge of the medical school application process and in their self-reported confidence. Participants reported meeting other AIAN students was highly beneficial and feeling connected to a community of AIAN health professionals after attending the workshop. Among the 25 participants who completed the 1-year follow-up survey, 12 (48.0%) indicated applying to medical school; all 12 of these participants were invited to interview, and 11 were offered acceptance to at least one medical school.

CONCLUSIONS

Completing the MSAW increased participants' knowledge, confidence, and sense of community. If other programs and institutions were to consider using the MSAW model to reduce barriers and provide supports specifically designed for AIANs before and during the medical school application process, medical schools may stand to further increase AIAN representation in the physician workforce and ultimately to decrease health inequities among AIANs.

The COVID-19 Community Research Partnership: a multistate surveillance platform for characterizing the epidemiology of the SARS-CoV-2 pandemic

The COVID-19 Community Research Partnership (CCRP) is a multisite surveillance platform designed to characterize the epidemiology of the Severe Acute Respiratory Syndrome Coronavirus-2 (SARS-COV-2) pandemic. This article describes the CCRP study design and methodology. The CCRP includes two prospective cohorts, one with six health systems in the mid-Atlantic and southern USA, and the other with six health systems in North Carolina. With enrollment beginning in April 2020, sites invited persons within their healthcare systems as well as community members to participate in daily surveillance for symptoms of COVID-like illnesses, testing, and risk behaviors. Participants with electronic health records (EHRs) were also asked to volunteer data access. Subsets of participants, representative of the general population and including oversampling of populations of interest, were selected for repeated at-home serology testing. By October 2021, 65 739 participants (62 261 adult and 3478 pediatric) were enrolled, with 89% providing syndromic data, 74% providing EHR data, and 70% participating in one of the two serology sub-studies. An average of 62% of the participants completed a daily survey at least once a week, and 55% of the serology kits were returned. The CCRP provides rich regional epidemiologic data and the opportunity to more fully characterize the risks and sequelae of SARS-CoV-2 infection.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

InspirE5: a participatory, internationally informed framework for health humanities curricula in health professions education

BACKGROUND

Reporting on the effect of health humanities teaching in health professions education courses to facilitate sharing and mutual exchange internationally, and the generation of a more interconnected body of evidence surrounding health humanities curricula is needed. This study asked, what could an internationally informed curriculum and evaluation framework for the implementation of health humanities for health professions education look like?

METHODS

The participatory action research approach applied was based on three iterative phases 1. Perspective sharing and collaboration building. 2. Evidence gathering 3. Development of an internationally relevant curriculum and evaluation framework for health humanities. Over 2 years, a series of online meetings, virtual workshops and follow up communications resulted in the production of the curriculum framework.

RESULTS

Following the perspective sharing and evidence gathering, the InspirE5 model of curriculum design and evaluation framework for health humanities in health professions education was developed. Five principal foci shaped the design of the framework.

ENVIRONMENT

Learning and political environment surrounding the program. Expectations: Graduate capabilities that are clearly articulated for all, integrated into core curricula and relevant to graduate destinations and associated professional standards.

EXPERIENCE

Learning and teaching experience that supports learners' achievement of the stated graduate capabilities.

EVIDENCE

Assessment of learning (formative and/or summative) with feedback for learners around the development of capabilities. Enhancement: Program evaluation of the students and teachers learning experiences and achievement. In all, 11 Graduate Capabilities for Health Humanities were suggested along with a summary of common core content and guiding principles for assessment of health humanities learning.

DISCUSSION

Concern about objectifying, reductive biomedical approaches to health professions education has led to a growing expansion of health humanities teaching and learning around the world. The InspirE5 curriculum and evaluation framework provides a foundation for a standardised approach to describe or compare health humanities education in different contexts and across a range of health professions courses and may be adapted around the world to progress health humanities education.

Parallel multi-structure decellularisation of a porcine three-dimensional right ventricular outflow tract valved xenograft for use in paediatric congenital cardiac surgery

Funding Acknowledgements

Type of funding sources: Foundation. Main funding source(s): British Heart Foundation

Background

Tetralogy of Fallot is the most common cyanotic congenital heart disease and requires right ventricular outflow tract (RVOT) replacement. RVOT substitutes are suboptimal, functionally deteriorating within a few years and necessitating a series of surgical reinterventions. An optimal prosthetic that mimics the structural and mechanical properties of native tissue is desirable. However, due to inadequate homo/autograft availability for neonates and infants, xenografts are commonly used in paediatric cardiac surgery. Current xenografts are limited by lack of growth, susceptibility to calcification, and limited remodelling capacity. Decellularisation to remove immunogenic antigens on the animal-derived tissue reduces the risk of graft rejection. Decellularisation conditions are critical: harsh treatment will disrupt extracellular matrix components vital for in vivo recellularisation; conversely, a too mild treatment may lead to incomplete cell removal and graft degeneration. Decellularisation of valved conduits poses a unique challenge as the valve structure differs significantly to that of the artery. The latter is thicker and stronger, requiring harsher detergents which could damage the valve.

Purpose

This research optimises an in vitro decellularisation protocol for simultaneous removal of porcine cells from the right ventricle (RV), pulmonary artery (PA), and pulmonary valve (PV). We ultimately plan to recellularise the cell-free RVOT scaffold with autologous mesenchymal stem cells via a tissue-engineering approach, endowing the xenograft with growth capacity and improved biocompatibility compared to existing products, thus overcoming the limitations of the currently used replacement grafts.

Methods

The integrated valved RVOT conduits were harvested from pigs and mounted in a temperature-controlled bioreactor chamber. Decellularisation solutions were circulated through the lumen and around the outside of the submerged conduit under constant flow, with extended sodium dodecyl sulfate and nuclease washes. Histological assessment of the RV, PA, and PV by Heamatoxylin and Eosin, for nuclei detection, and Elastin van Gieson’s staining, for elastin and collagen content, report on decellularisation success.

Results

Preliminary results demonstrate effective decellularisation of the RV, PA, and PV in both the valved conduit decellularised immediately after harvesting and following one freeze-thaw cycle. The ability to freeze RVOTs until needed would facilitate production of an accessible surgical product. Images reveal nuclei elimination in each tissue architecture whilst the extracellular matrix composition appears unchanged.

Conclusions

Concurrent multi-tissue decellularisation revealed promising structural results, however mechanical properties of the cell-free RVOT must be assessed to deem decellularisation successful. Further experiments are underway to evaluate the scaffold’s capacity to support mesenchymal stem cell repopulation.

Outcomes from a digital cardiovascular prevention and rehabilitation programme delivered in Ireland during COVID 19

Funding Acknowledgements

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Government of Ireland's Sláintecare Integration Fund Health Research Board, Ireland

Background & Aim

COVID 19 has accelerated the uptake and acceptance of digital health tools for the prevention and management of Cardiovascular Disease. With health systems being urged to learn from the pandemic and to reassess how they will deliver services in future, robust audit and evaluation of digital interventions are required to inform best practice.

This study aims to evaluate the clinical outcomes of a digital CVD prevention and rehabilitation programme which was established during COVID 19 to provide cardiac patients with efficient and timely access to a home-based, structured, comprehensive programme of care.

Methods

Developed and delivered by an interdisciplinary team (Nurse Prescriber, Physiotherapist, Dietitian, Cardiologist), the core components of this 12 week programme included, behavioural change support, lifestyle modification, medical risk factor management and electronic prescribing of cardio-protective medication. To support self-management, patients were provided with a Fitbit, blood pressure monitor and a workbook to support goal setting and overall tracking of progress. Patients were given access to a bespoke web-based platform and invited to attend weekly (2hr) group-based sessions, which included an exercise component and an interactive educational workshop.

Results

Over a 4 month period, 105 patients were referred with an uptake rate of 73% (n=77). Of these, 97% (n=75) enrolled in the programme, with an 85% (n=64) completion rate. Significant improvements in CVD risk factors were observed between initial and end of programme assessment. The proportion of patients meeting guideline-recommended physical activity targets increased from 14 to 82% (p<0.001), mean BMI (kg/m2) reduced from 28.7 to 27.7 (p<0.001), mean Mediterranean diet score improved from 5.2 to 7.3 (p<0.001), and anxiety and depression levels ≥8 (Hospital Anxiety and Depression score) both reduced by more than 50% (p<0.001). The proportions achieving the recommended blood pressure (<130/80 mmHg) and LDL cholesterol targets (<1.4 mmol/L) increased from 24 to 68% (p<0.001) and 14 to 41% (p<0.001), respectively.

Conclusion

Outcomes from this programme demonstrate that digital CVD prevention and rehabilitation programmes can achieve the recommended lifestyle, medical and therapeutic targets associated with reduced CVD events and improved health outcomes. This programme represents a scalable, accessible and effective option to deliver vital CVD preventive care in the patient’s home.

Pharmacokinetics and Macrophage Inhibitory Cytokine-1 Pharmacodynamics of the Murine Double Minute 2 Inhibitor, Navtemadlin (KRT-232) in Fed and Fasted Healthy Subjects

This single 60-mg dose, 4-period crossover study assessed the effect of food and formulation change on navtemadlin (KRT-232) pharmacokinetics (PK) and macrophage inhibitory cytokine-1 (MIC-1) pharmacodynamics. Healthy subjects (N = 30) were randomized to 3 treatment sequences, A: new tablet, fasted (reference, dosed twice); B: new tablet, 30 minutes after a high-fat meal (test 1); C: old tablet, fasted (test 2). PK/pharmacodynamic parameters were measured over 0 to 96 hours. Adverse events were mild without any discontinuations. No serious adverse events or deaths occurred. In treatment A, navtemadlin mean (coefficient of variation) maximum concentration (Cmax ) was 525 (66) ng/mL, at median time to maximum concentration (tmax ) of 2 hours. Mean (coefficient of variation) area under the plasma concentration-time curve from time 0 to time t (AUC0-t ) was 3392 (63.3) ng • h/mL, and arithmetic mean terminal half-life was 18.6 hours. Acyl glucuronide metabolite (M1)/navtemadlin AUC0-t ratio was 0.2, and urine excretion of navtemadlin was negligible. After a meal (B vs A), navtemadlin tmax was delayed by 1 hour. Geometric least squares means ratios (90%CI) for navtemadlin Cmax and AUC0-t were 102.7% (87.4-120.6) and 81.4% (76.2-86.9), respectively. Old vs new tablet fasted formulations (C vs A) had geometric least squares means ratios (90%CI) of 78.4% (72.0-85.3) for Cmax and 85.9% (80.5-91.7) for AUC0-t . MIC-1 Cmax and AUC were comparable across groups; tmax was delayed relative to navtemadlin tmax by ≈8 hours. Navtemadlin AUC0-t and MIC-1 AUC0-t correlated significantly. In conclusion, navtemadlin can be administered safely with or without food; the new formulation does not affect navtemadlin PK. The 60-mg navtemadlin dose elicited a reproducible and robust MIC-1 response that correlated well with navtemadlin exposure, indicating that murine double minute 2 target engagement leads to p53 activation.

Textbook outcome following oesophagectomy for cancer: international cohort study

Background

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

Methods

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

Results

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

Conclusion

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

Textbook outcome following oesophagectomy for cancer: international cohort study

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Seasonal deposition of marine debris on an important marine turtle nesting beach in Costa Rica

Marine debris pollution poses a threat for wildlife and can negatively impact the economy of communities whose livelihoods depend on tourism. Playa Norte, in northeastern Costa Rica, is an important nesting ground for four marine turtle species identified as vulnerable or endangered on the IUCN Red List. It is highly polluted but has low human occupancy. We conducted accumulation rate surveys following a standardized marine debris protocol from March 2016 to January 2018. Macro-debris was categorized by size and material type. Of the 191,030 debris items retrieved during the two-year study period, 96.2% of them were plastic. Debris accumulation was higher during the dry season (January - September). This study contributes towards understanding the drivers of marine debris pollution in critical wildlife nesting habitats; and informs managers and the local community on possible strategies to prevent and reduce marine pollution, thereby aiding in tourism derived economies.

A256 SURVEILLANCE OF SMALL, NON-FUNCTIONING, ASYMPTOMATIC PANCREATIC NEUROENDOCRINE TUMORS: THE BRITISH COLUMBIA EXPERIENCE

Background

Expert consensus surrounding surveillance for small, non-functioning, asymptomatic pancreatic neuroendocrine tumors (PNETs) remains conflicting. Recent observational studies have shown that surveillance is a safe strategy while large database studies show superior overall survival with surgical resection.

Aims

To describe the growth of small (&lt;2cm), non-functioning, asymptomatic PNETs undergoing surveillance at a tertiary hospital in British Columbia.

Methods

We conducted a retrospective case series of patients with biopsy-proven, non-functioning, asymptomatic PNETs which were &lt;2cm by RECIST criteria at diagnosis, who were followed through active surveillance at Vancouver General Hospital, British Columbia from February 1, 2011-February 1, 2021. Patients were included if serial imaging, whether by endoscopic ultrasound or cross-sectional imaging, was available for a minimum of 24 months.

Results

Of the 57 patients with pathology-proven PNETs that were identified, 14 cases were included after excluding those with resection within 1 year (n=17), lost to follow up (n=13), metastatic disease (n=6), size greater than 2cm at diagnosis (n=4), and with concurrent cancer (n=3). Included patients were predominantly female (n=10, 71%), Caucasian (n=8, 57%), and had a mean Charlson comorbidity index of 3.14. Mean PNET size at diagnosis was 12mm with standard deviation of 4.26mm. Tumors were located in the pancreatic head (n=4, 29%), body (n=6, 42%), and tail (n=4, 29%). Of 8 patients who had Ki67 stains, all were &lt;3%, and of 11 patients with mitotic index, all had &lt;2 mitotic figures. As such, of the 8 patients with available WHO grading, all were grade 1. The average follow-up was 49.6 months with an average tumor growth of 0.82mm per year. When grouping these tumors by growth, 9 (62%) tumors exhibited no growth, 2 tumors grew &lt;1mm per year, 2 tumors grew 1-1.5mm per year, and 1 tumor grew 7.7mm per year. Two cases (14%) of PNETs underwent surgical resection due to size surpassing 2 cm. No patients undergoing surveillance developed metastatic disease.

Conclusions

To our knowledge, we have performed the first Canadian series of small, low-grade PNETS and demonstrated that active surveillance is a safe strategy with most tumors exhibiting no growth of several years. Of the subset of PNETs which demonstrate progression, the preceding surveillance strategy did not disadvantage patients in terms of progression to metastases and allowed for delay of potentially morbid surgery. Further research with prospective studies and larger samples should be conducted.

Funding Agencies

CAG

Health Humanities curriculum and evaluation in health professions education: a scoping review

BACKGROUND

The articulation of learning goals, processes and outcomes related to health humanities teaching currently lacks comparability of curricula and outcomes, and requires synthesis to provide a basis for developing a curriculum and evaluation framework for health humanities teaching and learning. This scoping review sought to answer how and why the health humanities are used in health professions education. It also sought to explore how health humanities curricula are evaluated and whether the programme evaluation aligns with the desired learning outcomes.

METHODS

A focused scoping review of qualitative and mixed-methods studies that included the influence of integrated health humanities curricula in pre-registration health professions education with programme evaluate of outcomes was completed. Studies of students not enrolled in a pre-registration course, with only ad-hoc health humanities learning experiences that were not assessed or evaluated were excluded. Four databases were searched (CINAHL), (ERIC), PubMed, and Medline.

RESULTS

The search over a 5 year period, identified 8621 publications. Title and abstract screening, followed by full-text screening, resulted in 24 articles selected for inclusion. Learning outcomes, learning activities and evaluation data were extracted from each included publication.

DISCUSSION

Reported health humanities curricula focused on developing students' capacity for perspective, reflexivity, self- reflection and person-centred approaches to communication. However, the learning outcomes were not consistently described, identifying a limited capacity to compare health humanities curricula across programmes. A set of clearly stated generic capabilities or outcomes from learning in health humanities would be a helpful next step for benchmarking, clarification and comparison of evaluation strategy.

Postoperative outcomes in oesophagectomy with trainee involvement

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Management of haematoma after thyroid surgery: systematic review and multidisciplinary consensus guidelines from the Difficult Airway Society, the British Association of Endocrine and Thyroid Surgeons and the British Association of Otorhinolaryngology, Head and Neck Surgery

Haematoma after thyroid surgery can lead to airway obstruction and death. We therefore developed guidelines to improve the safety of peri‐operative care of patients undergoing thyroid surgery. We conducted a systematic review to inform recommendations, with expert consensus used in the absence of high‐quality evidence, and a Delphi study was used to ratify recommendations. We highlight the importance of multidisciplinary team management and make recommendations in key areas including: monitoring; recognition; post‐thyroid surgery emergency box; management of suspected haematoma following thyroid surgery; cognitive aids; post‐haematoma evacuation care; day‐case thyroid surgery; training; consent and pre‐operative communication; postoperative communication; and institutional policies. The guidelines support a multidisciplinary approach to the management of suspected haematoma following thyroid surgery through oxygenation and evaluation; haematoma evacuation; and tracheal intubation. They have been produced with materials to support implementation. While these guidelines are specific to thyroid surgery, the principles may apply to other forms of neck surgery. These guidelines and recommendations provided are the first in this area and it is hoped they will support multidisciplinary team working, improving care and outcomes for patients having thyroid surgery.

Evaluation of a 10-week lifestyle and weight management programme on cardiovascular disease risk factors in a group of people living with obesity referred from a specialist bariatric clinic

Funding Acknowledgements

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Health Service Executive Health and Wellbeing, Saolta University Healthcare Group

OnBehalf

Croí the West of Ireland Cardiac Foundation, Galway, Ireland and the National Institute for Prevention and Cardiovascular Health

Introduction

People living with obesity are at an increased risk of cardiovascular disease (CVD). While development of obesity is multifactorial, lifestyle modification is fundamental to obesity treatment and risk factor reduction. We sought to measure the effects of a structured lifestyle modification programme on the physical and mental health of people living with obesity.

Purpose

This study investigated the impact of a 10-week, community based, lifestyle modification programme on CVD risk factors in people living with obesity (BMI ≥35kg/m2 with a co-morbidity or BMI ≥40kg/m2) who were referred from a specialist bariatric service.

Methods

Delivered by an interdisciplinary team (Nurse, Dietitian & Physiotherapist) the programme included weekly group-based exercise sessions and health promotion workshops. A wide range of topics were addressed in workshops, including nutrition, food labels, emotional eating, physical activity, sedentary behaviour, stress management and CVD risk factor reduction. Outcomes were measured at initial and end of programme assessments.

Results

1122 people participated in the intervention between 2013 and 2019 with 78% (n = 877) completing the programme. At initial assessment 26.7% of participants had a diagnosis of type 2 diabetes; 37.3% were at high or very high risk of CVD; 44.7% were hypertensive and 31.4% had a history of depression. Mean BMI was 47.0kg/m2 with 56.4% of participants having a BMI &gt;45kg/m2. The intervention had significant positive impacts on key outcomes such as psychosocial health, lipid profiles, blood pressure, adiposity and cardiovascular fitness. One of the most significant outcomes observed was the improvement in psycho-social health. Scores of anxiety and depression, assessed using the HADS, decreased by 1.5 and 2.2 points respectively (p &lt;0.001). Mean EQ-VAS score increased by 11 points (p &lt;0.001). There were significant changes in total cholesterol levels with a mean reduction in total cholesterol from 4.69mmol/l to 4.54mmol/l (p &lt;0.001) and LDL cholesterol from 2.79mmol/l to 2.64mmol/l (p &lt;0.001). There were also significant improvements in blood pressure with mean systolic blood pressure reducing by 15.7mmHg (p &lt;0.001) and diastolic blood pressure reducing by 1.4mmHg (p &lt;0.001). For people with type 2 diabetes, there was an increase in those achieving the recommended HbA1c target (&lt;53mmol/l) from 47.6% to 57.4% (p &lt;0.001). Mean reduction in bodyweight was 2.0kg (p &lt;0.001), with 27.2% achieving a weight loss of &gt;3% of initial bodyweight. The percentage of participants achieving the recommended physical activity guidelines increased by 31% (p &lt;0.001).

Conclusions

A lifestyle modification programme delivered by an interdisciplinary team, aimed at individuals living with obesity, is not only acceptable to participants but also significantly reduces CVD risk factors. These findings should influence the design of future programmes and healthcare policies in Ireland and abroad.

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

BACKGROUND

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

METHOD

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

RESULTS

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

CONCLUSION

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

Non-ST elevation myocardial infarction; admission to angiogram time at a busy district general hospital

Funding Acknowledgements

Type of funding sources: None.

Background

Cardiovascular disease is the leading cause of morbidity and mortality worldwide. Timely management of acute coronary syndromes, including patients presenting with non-ST elevation myocardial infarction (NSTEMI), is crucial in improving outcomes and reducing mortality. Clinical Guideline 94 (CG94) by National Institute of Health and Care Excellence (NICE) states that patients presenting with a NSTEMI with an intermediate or higher risk score should be offered coronary angiography within 96 hours of admission to hospital.

Purpose

The purpose of this audit is to assess how well our General Hospital adhered to the recommended NSTEMI intervention set by the NICE guidelines.

Methods

Data was collected between September and December 2019 for patients admitted with an NSTEMI to the cardiology department at our General Hospital. Data was analysed using in-patient paper notes and Microsoft Excel.

Results

Of the 54 patients admitted with NSTEMI, 67% met the NICE guideline for angiogram within 96 hours of admission. The most common reason for delay was infection or raised inflammatory markers (28%). Other medical reasons include pulmonary oedema (11.1%), acute kidney injury (11.1%) and stroke (11.1%). Another notable reason for delay to angiogram was weekend admissions and wait for cardiology bed (22.2%). Six-month mortality rates showed that, 75% of deceased patients did not undergo an angiogram within 96 hours of admission.

Conclusion

We have an elderly population with multiple co-morbidities. Therefore, whilst patients are being managed for other acute medical problems they are deemed unfit for an immediate angiogram ultimately causing a delay. Furthermore, some patients were not referred to cardiology immediately after the NSTEMI event which causes delay in organising the angiogram. Finally, some patients were awaiting a cardiology bed in the Acute Admissions Unit. This causes delay as patients cannot undergo angiogram without a cardiology bed available for recovery. These delays are causing significant differences in the mortality rates of NSTEMI patients.

In order to address these issues, a hospital guideline for junior doctors regarding the management of NSTEMIs has been designed and distributed. The guideline emphasises the importance of early cardiology referral, the management of acute medical problems in NSTEMIs such pre-hydration to prevent acute kidney injury, and the medical management of NSTEMIs in line with the 2020 ESC guidelines. Finally, it would be useful to re-audit these findings to assess if mortality rates and adherence to the NICE and ESC guidelines improve following these interventions.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

896 Improving Intravenous Fluid Therapy to Reduce the Incidence of Acute Kidney Injury in Hip Fracture Patients

Background

Acute kidney injury (AKI) in hip fracture patients is associated with morbidity, mortality, and increased length of stay. To avoid this our unit policy recommends maintenance crystalloid IV fluids of &gt; 62.5mL/Hr for hip fracture patients.

Method

Three prospective audits, each including 100 consecutive acute hip fracture patients, were completed with interventional measures employed between each cycle. Data collection points included details of IV fluid administration and pre/post-operative presence of AKI. Interventions between cycles included implementation of admission/post-take checklist tools and various educational measures for Emergency Department, nursing and admitting team staff with dissemination of infographic posters, respectively.

Results

In cycle one and two, many patients received inadequate fluids (46/100 and 56/100 respectively). There was no significant difference in the incidence of AKI between patients receiving adequate or inadequate fluid in either cycle (p &lt; 0.05).

In cycle three, more patients received adequate fluids (79/100, p &lt; 0.05). Patients prescribed adequate fluids were less likely to develop post-operative AKI (2/79, 2.5% vs 3/21, 14.3%; p &lt; 0.05).

Discussion

This audit demonstrates the importance of administering appropriate IV fluid in hip fracture patients to avoid AKI. Improving coordination with Emergency Department and ward nursing/medical ward staff was a critical step in improving our unit’s adherence to policy.

Becoming a diagnostic agent: A collated ethnography of digital-sensory work in caregiving intra-actions

Sociological contributions on digital health have acknowledged the enduring significance of sensory work in diagnosis and practices of care. Previous explorations of these digital and sensory entanglements have focused separately on healthcare providers or patients/caregivers, rarely bringing these worlds together. Our analysis, based on the collation of ethnographic fieldwork in clinics, medical schools, and homes in Australia, offers rare insights into caregiver and practitioner perspectives. We interrogate the work involved in digital-sensory becoming, as caregivers (in our case parents) learn to assign diagnostic meaning to potential childhood disease. Working with Karen Barad's concept of 'intra-action', we demonstrate how diagnostic knowing is enacted between practitioners, parents, senses, and devices. We identify seven aspects of digital-sensory learning: attention to the change from normal; testing/searching for signs and symptoms; confirmation and direction from more experienced others; mimicry; analogy/metaphor; digital archiving; and reference to validated digitised signs. We found that this learning does not take place discretely in the clinic or at home. Doctors and parents both do digital-sensory work to register, co-witness, and mutually enact disease by interpreting signs and symptoms together in their caregiving intra-actions. Our article also champions collated ethnography as a methodological approach for making sense of complex assemblages in healthcare.

Honouring COVID-19 restrictions: A qualitative study of the virtual asd diagnostic pathway in a uk nhs camhs service

Introduction

The Multi-Agency Autism Team (MAAT) diagnose Autism Spectrum Disorder (ASD) in children and young people using a multi-stage assessment process. In March 2020, the UK went into lockdown due to the COVID-19 pandemic, affecting the MAAT’s ability to continue their typical diagnostic pathway.

Objectives

This qualitative study aimed to assess the effectiveness and feasibility of a virtual ASD diagnostic pathway.

Methods

From March – September; one hundred detailed developmental history assessments were conducted over the telephone, fifteen socially-distanced BOSA (Brief Observation of Symptoms of Autism) assessments were piloted, twenty-five multi-disciplinary formulation meeting were held over a video platform, and sixty diagnosis feedback consultations were conducted via telephone or video call. Structured interviews were conducted with clinicians and service-users.

Results

revealed that telephone developmental history assessments were generally preferable over face-to-face appointments, and video-based formulation meetings were effective, productive and resulted in higher clinician attendance. The qualitative data on feedback appointments was mixed. Clinicians felt that telephone appointments were less personable and ethical; whereas, video-based feedback appointments allowed for more empathy. However, the majority of service-users opted for tele-calls over video-calls for these appointments. Socially-distanced BOSAs obtained positive clinician feedback in general. Service-user feedback was mixed; some found the experience uncomfortable and unfamiliar, whilst others enjoyed the experience. Overall, service-users were content with the knowledge that it may support a diagnostic outcome for their child.

Conclusions

We concluded that the overall experience of the virtual ASD diagnostic pathway was a positive and informative process, identifying opportunities for permanent change to the service.

113 Improving Intravenous Fluid Therapy to Reduce the Incidence of Acute Kidney Injury in Elderly Hip Fracture Patients

Background

Acute kidney injury (AKI) in hip fracture patients is associated with morbidity, mortality, and increased length of stay. To avoid this our unit policy recommends maintenance crystalloid IV fluids of &gt;62.5 mL/Hr for hip fracture patients. However, audits have shown that many patients still receive inadequate IV fluids.

Methods

Three prospective audits, each including 100 consecutive acute hip fracture patients aged &gt;55, were completed with interventional measures employed between each cycle. Data collection points included details of IV fluid administration and pre/post-operative presence of AKI. Interventions between cycles included a revised checklist for admissions with a structured ward round tool for post-take ward round and various educational measures for Emergency Department, nursing and admitting team staff with dissemination of infographic posters, respectively.

Results

Cycle 1: 64/100 (64%) patients received adequate fluids. No significant difference in developing AKI post operatively was seen in patients given adequate fluids (2/64, 3.1%) compared to inadequate fluids (4/36, 11.1%; p = 0.107). More patients with pre-operative AKI demonstrated resolution of AKI with appropriate fluid prescription (5/6, 83.3%, vs 0/4, 0%, p &lt; 0.05) Cycle 2: Fewer patients were prescribed adequate fluids (54/100, 54%). There was no significant difference in terms of developing AKI post operatively between patients with adequate fluids (4/54, 7.4%) or inadequate fluids (2/46, 4.3%; p = 0.52). Resolution of pre-operative AKI was similar in patients with adequate or inadequate fluid administration (4/6, 67% vs 2/2, 100%). Cycle 3: More patients received adequate fluids (79/100, 79%, p &lt; 0.05). Patients prescribed adequate fluids were less likely to develop post-operative AKI than those receiving inadequate fluids (2/79, 2.5% vs 3/21, 14.3%; p &lt; 0.05).

Discussion

This audit demonstrates the importance of administering appropriate IV fluid in hip fracture patients to avoid AKI. Improving coordination with Emergency Department and ward nursing/medical ward staff was a critical step in improving our unit’s adherence to policy.

Evolutionary trait-based approaches for predicting future global impacts of plant pathogens in the genus Phytophthora

Plant pathogens are introduced to new geographical regions ever more frequently as global connectivity increases. Predicting the threat they pose to plant health can be difficult without in-depth knowledge of behaviour, distribution and spread. Here, we evaluate the potential for using biological traits and phylogeny to predict global threats from emerging pathogens.We use a species-level trait database and phylogeny for 179 Phytophthora species: oomycete pathogens impacting natural, agricultural, horticultural and forestry settings. We compile host and distribution reports for Phytophthora species across 178 countries and evaluate the power of traits, phylogeny and time since description (reflecting species-level knowledge) to explain and predict their international transport, maximum latitude and host breadth using Bayesian phylogenetic generalised linear mixed models.In the best-performing models, traits, phylogeny and time since description together explained up to 90%, 97% and 87% of variance in number of countries reached, latitudinal limits and host range, respectively. Traits and phylogeny together explained up to 26%, 41% and 34% of variance in the number of countries reached, maximum latitude and host plant families affected, respectively, but time since description had the strongest effect.Root-attacking species were reported in more countries, and on more host plant families than foliar-attacking species. Host generalist pathogens had thicker-walled resting structures (stress-tolerant oospores) and faster growth rates at their optima. Cold-tolerant species are reported in more countries and at higher latitudes, though more accurate interspecific empirical data are needed to confirm this finding. Policy implications. We evaluate the potential of an evolutionary trait-based framework to support horizon-scanning approaches for identifying pathogens with greater potential for global-scale impacts. Potential future threats from Phytophthora include Phytophthora x heterohybrida, P. lactucae, P. glovera, P. x incrassata, P. amnicola and P. aquimorbida, which are recently described, possibly under-reported species, with similar traits and/or phylogenetic proximity to other high-impact species. Priority traits to measure for emerging species may be thermal minima, oospore wall index and growth rate at optimum temperature. Trait-based horizon-scanning approaches would benefit from the development of international and cross-sectoral collaborations to deliver centralised databases incorporating pathogen distributions, traits and phylogeny.

Perioperative intravenous contrast administration and the incidence of acute kidney injury after major gastrointestinal surgery: prospective, multicentre cohort study

BACKGROUND

This study aimed to determine the impact of preoperative exposure to intravenous contrast for CT and the risk of developing postoperative acute kidney injury (AKI) in patients undergoing major gastrointestinal surgery.

METHODS

This prospective, multicentre cohort study included adults undergoing gastrointestinal resection, stoma reversal or liver resection. Both elective and emergency procedures were included. Preoperative exposure to intravenous contrast was defined as exposure to contrast administered for the purposes of CT up to 7 days before surgery. The primary endpoint was the rate of AKI within 7 days. Propensity score-matched models were adjusted for patient, disease and operative variables. In a sensitivity analysis, a propensity score-matched model explored the association between preoperative exposure to contrast and AKI in the first 48 h after surgery.

RESULTS

A total of 5378 patients were included across 173 centres. Overall, 1249 patients (23·2 per cent) received intravenous contrast. The overall rate of AKI within 7 days of surgery was 13·4 per cent (718 of 5378). In the propensity score-matched model, preoperative exposure to contrast was not associated with AKI within 7 days (odds ratio (OR) 0·95, 95 per cent c.i. 0·73 to 1·21; P = 0·669). The sensitivity analysis showed no association between preoperative contrast administration and AKI within 48 h after operation (OR 1·09, 0·84 to 1·41; P = 0·498).

CONCLUSION

There was no association between preoperative intravenous contrast administered for CT up to 7 days before surgery and postoperative AKI. Risk of contrast-induced nephropathy should not be used as a reason to avoid contrast-enhanced CT.

Sticky models

This paper explores the material histories which influence contemporary medical education. Using two obstetric simulators found in the distinct teaching environments of the University of Development Studies in the north of Ghana and Maastricht University in the south of the Netherlands, this paper deconstructs the material conditions which shape current practice in order to emphasise the past practices that remain relevant, yet often invisible, in modern medicine. Building on conceptual ideas drawn from STS and the productive tensions which emerge from close collaboration between historians and anthropologists, we argue that the pull of past practice can be understood as a form of friction, where historical practices ‘stick’ to modern materialities. We argue that the labour required for the translation of material conditions across both time and space is expressly relevant for the ongoing use and future development of medical technologies.

Echo workforce development in the Fiji Islands

Echocardiography has a wide scope of practice and requires many years of training and experience for one to be proficient; however, contextualised echo may be taught for the purpose of screening for rheumatic heart disease (RHD). In recent experience in the Fiji Islands, an echo workforce training programme was implemented with the intention of teaching general sonographers and physicians echo for the purpose of screening RHD with very positive results. This course was completed over three separate one week courses in a clinical setting.

132 Introduction of F508del human mutation into the CFTR gene of sheep fetal fibroblasts using CRISPR/Cas9 ribonucleoprotein

Cystic fibrosis (CF) is an autosomal recessive genetic disease that affects over 30 000 people in the United States and is caused by mutations in the cystic fibrosis transmembrane conductance regulator (CFTR) gene. The CFTR protein is a cAMP-regulated C− channel responsible for regulation of anion transport, primarily in the epithelial cells. We have previously generated a sheep model of CF by genetically inactivating the CFTR gene (Fan et al. 2018 JCI Insight 3, e123529). The newborn CFTR −/− sheep develops severe disease consistent with CF pathology in humans. The CF model is extremely valuable for understanding the developmental aspects of CF disease, as sheep have been used extensively in the study of human fetal growth and development. Sheep, like humans, typically give birth to only one or two offspring in each pregnancy, which make them more suitable than many other species for testing prenatal gene-editing treatments. Thus, in this new study, we are working on the generation of F508del sheep CF model. The F508del mutation was chosen because it is the most common mutation in the human CFTR gene (~70%). This mutation is characterised by the deletion of the CTT nucleotides, which ultimately deletes the phenylalanine residue at position 508. The F508del mutation causes misfolding of the CFTR protein, which is further degraded by proteases. Even though several CFTR modulators are available, they are not effective in all patients. Additionally, they cannot reverse deleterious prenatal CF manifestations. Hence, this model will be valuable for evaluating both prenatal drug and gene therapies. Here, we used a CRISPR/Cas9 gene-editing approach to introduce the F508del mutation into the sheep genome. We designed an sgRNA targeting exon 11 of the sheep CFTR gene using the Benchling software (https://benchling.com/academic). The sgRNA was synthesised by Synthego and Cas9 purchased from ThermoFisher. Using the Lonza-4D-Nucleofector system, Cas9/sgRNA ribonucleoprotein complex was transfected into sheep fetal fibroblasts (SFFs), along with 100bp single-stranded oligodeoxynucleotide, flanking the F508del mutation, for the homology-directed repair. The transfected cells were subsequently cultured in Dulbecco's modified Eagle's medium, supplemented with 15% fetal bovine serum and 1% penicillin, and incubated at 38.5°C. Two days post-transfection, SFFs were seeded individually into five 96-well plates by limited dilution. After seven days, the individual colonies were expanded into 24-well plates and cultured for three more days. A total of 56 single-cell-derived SFF colonies were isolated. The presence of F508del mutation was confirmed by amplifying the PCR products of the exon 11 flanking the mutation site and subjecting each amplicon to Sanger sequencing. The sequencing results indicated that the indels (insertion/deletion) were introduced in 49 out of 56 (87.5%) of the colonies, and four (7.14%) of them were confirmed to have biallelic F508del mutations based on sequencing peaks. Therefore, we successfully introduced the F508del mutation in SFFs that will be used for the production of F508del CF sheep by somatic cell nuclear transfer.

Human model of burn injury that quantifies the benefit of cooling as a first aid measure

BACKGROUND

Burn injuries are a major cause of morbidity and mortality worldwide. Cooling is widely practised as a first aid measure, but the efficacy of cooling burns in human skin has not been demonstrated. A safe, consistent, ethically acceptable model of burning and cooling in live human skin in vivo was developed, and used to quantify the effects of cooling.

METHODS

Novel apparatus was manufactured to create and cool burns in women who were anaesthetized for breast reconstruction surgery using a deep inferior epigastric artery perforator flap. Burns were excised between 1 and 3 h after creation, and analysed using histopathological assessment.

RESULTS

All 25 women who were approached agreed to take part in the study. There were no adverse events. Increased duration of contact led to increased burn depth, with a contact time of 7·5 s at 70°C leading to a mid-dermal burn. Burn depth progressed over time following injury, but importantly this was modified by cooling the burn at 16°C for 20 min. On average, cooling salvaged 25·2 per cent of the dermal thickness.

CONCLUSION

This study demonstrated the favourable effects of cooling on human burns. Public heath messaging should emphasize cooling as first aid for burns. This model will allow analysis of the molecular effects of cooling burns, and provide a platform for testing novel therapies aimed at reducing the impact of burn injury.

TNF-derived peptides inhibit tumour growth and metastasis through cytolytic effects on tumour lymphatics

Tumour necrosis factor (TNF) is a multi-functional cytokine with profound and diverse effects on physiology and pathology. Identifying the molecular determinants underlying the functions and pathogenic effects of TNF is key to understanding its mechanisms of action and identifying new therapeutic opportunities based on this important molecule. Previously, we showed that some evolutionarily conserved peptides derived from TNF could induce cell death (e.g. apoptosis and/or necrosis), a feature of immune defence mechanisms shared by many vertebrates. In this study, we demonstrated that necrosis-inducing peptide P16 kills human glioblastoma cancer cells and primary human hepatoma or renal cancer cells isolated from patients who had not responded to standard treatments. Importantly, we show that the necrosis-inducing peptide P1516 significantly improves survival by inhibiting tumour metastasis in a 4T1 breast cancer syngeneic graft mouse model. Because the lymphatic system is an important metastatic route in many cancers, we also tested the effect of TNF-derived peptides on monolayers of primary human lymphatic endothelial cells (hDLEC) and found that they increased junctional permeability by inducing cytoskeletal reorganization, gap junction formation and cell death. Transmission electron microscopy imaging evidence, structural analysis and in-vitro liposome leakage experiments strongly suggest that this killing is due to the cytolytic nature of these peptides. P1516 provides another example of a pro-cytotoxic TNF peptide that probably functions as a cryptic necrotic factor released by TNF degradation. Its ability to inhibit tumour metastasis and improve survival may form the basis of a novel approach to cancer therapy.