Slicing through silos: Development and evaluation of a hospital-based telehealth hepatitis C virus treatment program

BACKGROUND

There exist many barriers to hepatitis C virus (HCV) treatment for those with substance use disorder (SUD) or who lack access to routine medical care. A hospital-based telehealth program was developed to provide treatment opportunities for hospitalized patients living with HCV.

METHODS

This single site prospective cohort study conducted from July 2022 to March 2023 aimed to measure linkage to care with an HCV clinician and initiation of HCV treatment in hospitalized patients. Patients were assessed in-person by a social worker then seen via telehealth by a clinician who prescribed either glecaprevir/pibrentasvir or sofosbuvir/velpatasvir. Treatment was initiated with pharmacist assistance. The team conducted in-person and/or telephonic outreach during and after hospitalization. Cure was confirmed by sustained virologic response at 12 weeks (SVR12) post-treatment.

RESULTS

A total of 25 patients were enrolled and completed telehealth visits. All patients had a history of SUD and 18 (72 %) were unstably housed. Nineteen patients (76 %) initiated treatment, and 14 (56 %) successfully completed treatment. Twelve patients (48 %) completed post-treatment labs, including two who prematurely discontinued treatment. Eleven patients (44 %) achieved confirmed cure with SVR12.

CONCLUSION

A hospital-based, multidisciplinary telehealth program can be an innovative care model to successfully treat HCV in a difficult-to-treat patient populations.

Transferring inpatients between wards drives large nosocomial COVID-19 outbreaks, Wales, 2020-22: a matched case-control study using routine and enhanced surveillance data

BACKGROUND

The role of the hospital environment in the spread of COVID-19 is unclear.

AIM

To measure associations between ward characteristics and outbreak size to inform mitigations.

METHODS

Wards with large (case wards) and small (control wards) outbreaks in three acute hospitals were compared. Cases were healthcare-associated COVID-19 inpatients (positive polymerase chain reaction test ≥8 days post admission). Case wards were adult medical/surgical wards with ≥10 cases within rolling 14-day periods, between April 1st, 2020 and April 30th, 2022. Control wards were equivalents with 2-9 cases. Demographic and laboratory data were extracted from routine surveillance systems. Continuous data were aggregated fortnightly and analysed as binary variables according to median values. Each case ward was compared with two control wards matched on outbreak start date (±14 days) to calculate odds ratios (ORs) and 95% confidence intervals (95% CIs) using univariable and conditional multivariable logistic regression.

FINDINGS

From 170 outbreaks (median: 5 cases; interquartile range: 2-9), 35 case wards were identified. Community admissions were lower in case wards vs control wards (5 vs 10 median admissions; P<0.01, respectively), whereas transfers between wards within the same hospital were higher (58 vs 29 median transfers; P<0.01, respectively). Wards with more transfers in the preceding fortnight were significantly more likely to experience a large outbreak (≥35 vs <35 transfers; adjusted OR: 9.08; 95% CI: 2.5-33).

CONCLUSION

We recommend safely minimizing patient movements, such as by asking clinicians to record the rationale for transfer, to reduce the likelihood of disease transmission.

A protein-proximity screen reveals Ebola virus co-opts the mRNA decapping complex through the scaffold protein EDC4

The interaction of host and Ebola virus (EBOV) proteins is required for establishing infection of the cell. To identify protein binding partners, a proximity-dependent protein interaction screen was performed for six EBOV proteins. Hits were computationally mapped onto a human protein-protein interactome and then annotated with viral proteins to reveal known and previously undescribed EBOV-host protein interactions and processes. Importantly, this approach efficiently arranged proteins into functional complexes associated with single viral proteins. Focused characterization of interactions between EBOV VP35 and the mRNA decapping complex demonstrated that VP35 binds the scaffold protein EDC4 through the C-terminal subdomain, with each protein found associated in EBOV-infected cells. Mechanistically, depletion of three components of the complex each similarly inhibited viral replication by reducing early viral RNA synthesis. Overall, we demonstrate successful identification of EBOV protein interaction with entire cellular machines, providing a deeper understanding of replication mechanism for therapeutic intervention.

Tumor Regression upon Intratumoral and Subcutaneous Dosing of the STING Agonist ALG-031048 in Mouse Efficacy Models

Stimulator of interferon genes (STING) agonists have shown potent anti-tumor efficacy in various mouse tumor models and have the potential to overcome resistance to immune checkpoint inhibitors (ICI) by linking the innate and acquired immune systems. First-generation STING agonists are administered intratumorally; however, a systemic delivery route would greatly expand the clinical use of STING agonists. Biochemical and cell-based experiments, as well as syngeneic mouse efficacy models, were used to demonstrate the anti-tumoral activity of ALG-031048, a novel STING agonist. In vitro, ALG-031048 is highly stable in plasma and liver microsomes and is resistant to degradation via phosphodiesterases. The high stability in biological matrices translated to good cellular potency in a HEK 293 STING R232 reporter assay, efficient activation and maturation of primary human dendritic cells and monocytes, as well as long-lasting, antigen-specific anti-tumor activity in up to 90% of animals in the CT26 mouse colon carcinoma model. Significant reductions in tumor growth were observed in two syngeneic mouse tumor models following subcutaneous administration. Combinations of ALG-031048 and ICIs further enhanced the in vivo anti-tumor activity. This initial demonstration of anti-tumor activity after systemic administration of ALG-031048 warrants further investigation, while the combination of systemically administered ALG-031048 with ICIs offers an attractive approach to overcome key limitations of ICIs in the clinic.

Predictors and moderators of the response of adults with intellectual disabilities and depression to behavioural activation and guided self-help therapies

BACKGROUND

No previous studies have reported predictors and moderators of outcome of psychological therapies for depression experienced by adults with intellectual disabilities (IDs). We investigated baseline variables as outcome predictors and moderators based on a randomised controlled trial where behavioural activation was compared with guided self-help.

METHODS

This study was an exploratory secondary data analysis of data collected during a randomised clinical trial. Participants (n = 161) were randomised to behavioural activation or guided self-help and followed up for 12 months. Pre-treatment variables were included if they have previously been shown to be associated with an increased risk of having depression in adults with IDs or have been reported as a potential predictor or moderator of outcome of treatment for depression with psychological therapies. The primary outcome measure, the Glasgow Depression Scale for Adults with Learning Disabilities (GDS-LD), was used as the dependant variable in mixed effects regression analyses testing for predictors and moderators of outcome, with baseline GDS-LD, treatment group, study centre and antidepressant use as fixed effects, and therapist as a random effect.

RESULTS

Higher baseline anxiety (mean difference in outcome associated with a 1 point increase in anxiety 0.164, 95% confidence interval [CI] 0.031, 0.297; P = 0.016), lower performance intelligence quotient (IQ) (mean difference in outcome associated with a 1 point increase in IQ 0.145, 95% CI 0.009, 0.280; P = 0.037) and hearing impairment (mean difference 3.449, 95% CI 0.466, 6.432; P = 0.024) were predictors of poorer outcomes, whilst greater severity of depressive symptoms at baseline (mean difference in outcome associated with 1 point increase in depression -0.160, 95% CI -0.806, -0.414; P < 0.001), higher expectation of change (mean difference in outcome associated with a 1 point increase in expectation of change -1.013, 95% CI -1.711, -0.314; p 0.005) and greater percentage of therapy sessions attended (mean difference in outcome with 1 point increase in percentage of sessions attended -0.058, 95% CI -0.099, -0.016; P = 0.007) were predictors of more positive outcomes for treatment after adjusting for randomised group allocation. The final model included severity of depressive and anxiety symptoms, lower WASI performance IQ subscale, hearing impairment, higher expectation of change and percentage of therapy sessions attended and explained 35.3% of the variance in the total GDS-LD score at 12 months (R2  = 0.353, F4, 128  = 17.24, P < 0.001). There is no evidence that baseline variables had a moderating effect on outcome for treatment with behavioural activation or guided self-help.

CONCLUSIONS

Our results suggest that baseline variables may be useful predictors of outcomes of psychological therapies for adults with IDs. Further research is required to examine the value of these potential predictors. However, our findings suggest that therapists consider how baseline variables may enable them to tailor their therapeutic approach when using psychological therapies to treat depression experienced by adults with IDs.

A chromosome-scale genome assembly and evaluation of mtDNA variation in the willow leaf beetle Chrysomela aeneicollis

The leaf beetle Chrysomela aeneicollis has a broad geographic range across Western North America but is restricted to cool habitats at high elevations along the west coast. Central California populations occur only at high altitudes (2,700-3,500 m) where they are limited by reduced oxygen supply and recent drought conditions that are associated with climate change. Here, we report a chromosome-scale genome assembly alongside a complete mitochondrial genome and characterize differences among mitochondrial genomes along a latitudinal gradient over which beetles show substantial population structure and adaptation to fluctuating temperatures. Our scaffolded genome assembly consists of 21 linkage groups; one of which we identified as the X chromosome based on female/male whole genome sequencing coverage and orthology with Tribolium castaneum. We identified repetitive sequences in the genome and found them to be broadly distributed across all linkage groups. Using a reference transcriptome, we annotated a total of 12,586 protein-coding genes. We also describe differences in putative secondary structures of mitochondrial RNA molecules, which may generate functional differences important in adaptation to harsh abiotic conditions. We document substitutions at mitochondrial tRNA molecules and substitutions and insertions in the 16S rRNA region that could affect intermolecular interactions with products from the nuclear genome. This first chromosome-level reference genome will enable genomic research in this important model organism for understanding the biological impacts of climate change on montane insects.

Childhood-Onset Lupus Nephritis in the Childhood Arthritis and Rheumatology Research Alliance Registry: Short-Term Kidney Status and Variation in Care

OBJECTIVE

The goal was to characterize short-term kidney status and describe variation in early care utilization in a multicenter cohort of patients with childhood-onset systemic lupus erythematosus (cSLE) and nephritis.

METHODS

We analyzed previously collected prospective data from North American patients with cSLE with kidney biopsy-proven nephritis enrolled in the Childhood Arthritis and Rheumatology Research Alliance (CARRA) Registry from March 2017 through December 2019. We determined the proportion of patients with abnormal kidney status at the most recent registry visit and applied generalized linear mixed models to identify associated factors. We also calculated frequency of medication use, both during induction and ever recorded.

RESULTS

We identified 222 patients with kidney biopsy-proven nephritis, with 64% class III/IV nephritis on initial biopsy. At the most recent registry visit at median (interquartile range) of 17 (8-29) months from initial kidney biopsy, 58 of 106 patients (55%) with available data had abnormal kidney status. This finding was associated with male sex (odds ratio [OR] 3.88, 95% confidence interval [95% CI] 1.21-12.46) and age at cSLE diagnosis (OR 1.23, 95% CI 1.01-1.49). Patients with class IV nephritis were more likely than class III to receive cyclophosphamide and rituximab during induction. There was substantial variation in mycophenolate, cyclophosphamide, and rituximab ever use patterns across rheumatology centers.

CONCLUSION

In this cohort with predominately class III/IV nephritis, male sex and older age at cSLE diagnosis were associated with abnormal short-term kidney status. We also observed substantial variation in contemporary medication use for pediatric lupus nephritis between pediatric rheumatology centers. Additional studies are needed to better understand the impact of this variation on long-term kidney outcomes.

Can We Miniaturize CT Technology for a Successful Mobile Stroke Unit Roll-Out?

Mortality from stroke remains high in Australia, especially for patients located outside the metropolitan cities. This is because they have limited access to specialized stroke facilities for optimal stroke treatment. Mobile stroke units have the capability to take CT scanners out to the patient however current CT commercial scanner designs are large and heavy. As such, this paper aims to design and develop a lightweight CT scanner for use in a mobile stroke unit (either road-based or air-based ambulance) to bring healthcare solution to patients in the rural and remote areas. We used the engineering design optimization approach to redesign and reduce the weight of the existing CT scanner with without compromised it structural performance. We managed to reduce the weight the CT scanner by three-fold while reducing design costs by allowing numerous simulations to be performed using computer software to achieve our design goals. The results are not only useful to optimize CT scanner structure to retrofit on a mobile stroke unit, but also bring the medical device solution to the market and support scalable solution to the larger community. Such an advance will allow for improved equity in healthcare whereby patients can be treated irrespective of location.

Assay interference leading to erroneous pregnancy-associated plasma protein-A results

Linked article: There is a comment on this article by Matyszkiewicz et al. Click here to view the Correspondence.

A157 FIT-POSITIVE COLONOSCOPY FINDINGS IN NOVA SCOTIA STRATIFIED BY SEX, RACE, AND REGIONAL POPULATION DENSITY

Background

Population-based colorectal cancer (CRC) screening programs aim to minimize disparities in CRC rates through universal access. However, Canadian CRC mortality rates remain inversely associated with socioeconomic status and rural residence. In the United States some racialized groups have higher rates of advanced adenomas and CRC. Little is known about pre-cancerous findings or CRC mortality amongst racialized groups in Canada because race and ethnicity data are not routinely collected.

Purpose

To determine whether FIT-positive colonoscopy incident adenomas and CRC differ on the basis of sex, race, and regional population density in a provincial CRC screening program.

Method

In this retrospective cohort study drawn from the Nova Scotia Colon Cancer Prevention Program database, we identified adults who had a positive FIT from 2011 to 2021. This report describes incident adenomas and CRC, stratified by sex, race (white vs. racialized groups), and regional population density (urban vs. rural). Racialized groups included those who self-identified as Black/African Canadian, Asian, Middle Eastern and Indigenous. Urban was defined as population centers with more than 5000 individuals. Colonoscopy findings were categorized as no findings, low-risk adenoma (LRA), high-risk adenoma (HRA), or CRC. Comparison between categorical variables was performed with a chi-square test and a t-test for continuous variables. P-value <0.05 was considered significant.

Result(s)

41,209 adults (mean age 63.9) had a positive FIT and 34,636 went on to have a colonoscopy offered by the screening program. The FIT-positive colonoscopy participation rate was 84%. Of the 16% overall with a positive FIT but no screening program colonoscopy, 83% had a program consultation but did not proceed with endoscopy for unspecified reasons, 9% declined, and 8.2% are unknown. The overall rate of CRC was 2.4% (n=825) and the adenoma-detection rate was 60.4% (n=20,932). CRC (mean age 65.4) and HRA (mean age 64.6) were associated with older age (p <0.01). Males were more likely to have HRA (38.4% of males) or LRA (26.6% of males) identified compared to females, and females were more likely to have no colonoscopy findings (47.8% of females). CRC was more likely to be identified in urban (2.8%) than rural sub-populations (2.0%). No difference in adenomas or CRC incident rates were noted between white and racialized sub-groups.

Image

Conclusion(s)

This analysis of a provincial CRC screening program suggests that males and urban sub-populations had more high-risk findings during FIT-positive colonoscopies. In the first reported Canadian data, incident rates of adenomas and CRC were similar in white and racialized sub-groups.

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Disclosure of Interest

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Factors affecting turnaround time of SARS-CoV-2 sequencing for inpatient infection prevention and control decision making: analysis of data from the COG-UK HOCI study

BACKGROUND

Barriers to rapid return of sequencing results can affect the utility of sequence data for infection prevention and control decisions.

AIM

To undertake a mixed-methods analysis to identify challenges that sites faced in achieving a rapid turnaround time (TAT) in the COVID-19 Genomics UK Hospital-Onset COVID-19 Infection (COG-UK HOCI) study.

METHODS

For the quantitative analysis, timepoints relating to different stages of the sequencing process were extracted from both the COG-UK HOCI study dataset and surveys of study sites. Qualitative data relating to the barriers and facilitators to achieving rapid TATs were included from thematic analysis.

FINDINGS

The overall TAT, from sample collection to receipt of sequence report by infection control teams, varied between sites (median 5.1 days, range 3.0-29.0 days). Most variation was seen between reporting of a positive COVID-19 polymerase chain reaction (PCR) result to sequence report generation (median 4.0 days, range 2.3-27.0 days). On deeper analysis, most of this variability was accounted for by differences in the delay between the COVID-19 PCR result and arrival of the sample at the sequencing laboratory (median 20.8 h, range 16.0-88.7 h). Qualitative analyses suggest that closer proximity of sequencing laboratories to diagnostic laboratories, increased staff flexibility and regular transport times facilitated a shorter TAT.

CONCLUSION

Integration of pathogen sequencing into diagnostic laboratories may help to improve sequencing TAT to allow sequence data to be of tangible value to infection control practice. Adding a quality control step upstream to increase capacity further down the workflow may also optimize TAT if lower quality samples are removed at an earlier stage.

Detailed analysis of in-hospital transmission of SARS-CoV-2 using whole genome sequencing

BACKGROUND

Hospital transmission of SARS-CoV-2 has proved difficult to control, with healthcare-associated infections troublesome throughout.

AIM

To understand factors contributing to hospital transmission of infections, which is necessary for containing spread.

METHODS

An outbreak of 56 staff and patient cases of COVID-19 over a 31-day period in a tertiary referral unit is presented, with at least a further 29 cases identified outside of the unit and the hospital by whole genome sequencing (WGS).

FINDINGS

Transmission is documented from staff to staff, staff to patients, and patients to staff, showing disruption of a tertiary referral service, despite implementation of nationally recommended control measures, superior ventilation, and use of personal protective equipment. There was extensive spread from the index case, despite this patient spending only 10 h bed bound on the ward in strict cubicle isolation and with an initial single target low level (C_T = 32) polymerase chain reaction test.

CONCLUSION

This investigation highlights how effectively and rapidly SARS-CoV-2 can spread in certain circumstances. It raises questions about infection control measures in place at the time and calls into question the premise that transmissibility can be reliably detected by using lower sensitivity rapid antigen lateral flow tests. We also highlight the value of early intervention in reducing impact as well as the value of WGS in understanding outbreaks.

Screw-only fibular construct for Weber B ankle fractures: A retrospective clinical and cost comparison to assess feasibility for resource-limited settings

INTRODUCTION

Ankle fractures are one of the most common injuries sustained worldwide, with the majority being isolated lateral malleolus fractures. The majority of the world's population live in Low and Middle Income Countries (LMIC), where implant cost may limit surgical treatment of ankle fractures. We investigate if Weber B ankle fractures could be effectively treated with a lower-cost technique using two screws between the fibula and the tibia to neutralize an interfragmentary lag screw.

METHODS

After IRB approval, consecutive patients from January 1, 2020 to December 31, 2020 with Weber-B ankle fractures were treated using AO technique (AOT) with plate osteosynthesis neutralizing an interfragmentary screw. Syndesmotic injuries, as well as injuries to the medial malleolus or foot were treated according to the surgeon's preferences. From January 1, 2021 to December 31, 2021 these injuries were treated with a screw-only technique (SOT) with two fibula pro tibia screws to neutralize an interfragmentary screw. Patient demographics including age, sex, BMI, smoking status, associated rheumatoid arthritis, and associated diabetes mellitus were recorded. The primary outcome variable was a stable radiographic mortise at six weeks post-surgery, secondary outcome variables included clinical union, infection, hardware removal, and implant cost for lateral malleolar fixation charged to the hospital.

RESULTS

Seventeen AOT and 10 SOT constructs were included. Demographic characteristics were similar between groups. All fractures maintained a stable mortise with clinical union at 6 weeks without infection. There was a statistically significant difference in hardware removal (17.6% AOT, 50% SOT, p = 0.012). The average implant cost to the hospital of the lateral malleolar fixation was significantly less in the SOT group ($592 (SD $229)), compared to the AOT group ($1,949.97 (SD $562)), (p < 0.0001).

CONCLUSION

We introduce proof of concept of a novel lower-cost fixation strategy for Weber B ankle fractures that maintained a stable mortise with clinical union at six weeks post-surgery. However, there was a significantly higher rate of hardware removal following fixation with a screw-only construct.

Intraarticular steroids as DMARD-sparing agents for juvenile idiopathic arthritis flares: Analysis of the Childhood Arthritis and Rheumatology Research Alliance Registry

BACKGROUND

Children with juvenile idiopathic arthritis (JIA) who achieve a drug free remission often experience a flare of their disease requiring either intraarticular steroids (IAS) or systemic treatment with disease modifying anti-rheumatic drugs (DMARDs). IAS offer an opportunity to recapture disease control and avoid exposure to side effects from systemic immunosuppression. We examined a cohort of patients treated with IAS after drug free remission and report the probability of restarting systemic treatment within 12 months.

METHODS

We analyzed a cohort of patients from the Childhood Arthritis and Rheumatology Research Alliance (CARRA) Registry who received IAS for a flare after a period of drug free remission. Historical factors and clinical characteristics and of the patients including data obtained at the time of treatment were analyzed.

RESULTS

We identified 46 patients who met the inclusion criteria. Of those with follow up data available 49% had restarted systemic treatment 6 months after IAS injection and 70% had restarted systemic treatment at 12 months. The proportion of patients with prior use of a biologic DMARD was the only factor that differed between patients who restarted systemic treatment those who did not, both at 6 months (79% vs 35%, p < 0.01) and 12 months (81% vs 33%, p < 0.05).

CONCLUSION

While IAS are an option for all patients who flare after drug free remission, it may not prevent the need to restart systemic treatment. Prior use of a biologic DMARD may predict lack of success for IAS. Those who previously received methotrexate only, on the other hand, are excellent candidates for IAS.

Paroxysmal atrial fibrillation ablation with a novel flexible tip radiofrequency catheter incorporating contact force sensing: acute results of the TactiFlex AF IDE trial

Background

Catheter ablation is an established therapy for paroxysmal atrial fibrillation (PAF). The TactiFlex™ Ablation Catheter, Sensor-Enabled™ (TactiFlex SE) is a next-generation radiofrequency ablation catheter incorporating highly accurate fiber optics-based contact force sensing technology with a flexible, laser-cut tip.

Purpose

To demonstrate that ablation with TactiFlex SE is safe and effective for the treatment of drug refractory, symptomatic PAF.

Methods

The TactiFlex AF IDE is a prospective, non-randomized, multi-center clinical study which enrolled 355 subjects worldwide. Enrollment in the main study began on June 26, 2020 and completed on June 18, 2021. Subjects underwent de novo Pulmonary Vein Isolation (PVI) and, if indicated, a Cavotricuspid Isthmus ablation (CTI line) for CTI-dependent atrial flutter.

Results

Subjects were divided into two as treated subgroups: High Standard Power (HSP, n=189), defined as subjects with 100% of left atrial lesions ablated at ≥40 W, and Low Standard Power (LSP, n=119), defined as subjects with at least one left atrial lesion ablated at &lt;40W. First pass success, defined as isolation of all pulmonary veins (PVs) confirmed after a minimum 20 min waiting period was achieved in 93.5% (175/186) and 84.5% (98/116) of HSP and LSP subjects, respectively (p=0.0104). Significant decreases in the HSP versus LSP procedures were also seen in total procedure time (112.0 min [89.0, 139.5] and 149.0 [115.0, 182.0], respectively [p&lt;0.001]), total RF time for PV ablation (14.0 min [11.0, 19.0] and 29.0 [19.0, 41.0], respectively [p&lt;0.0001]), total fluoroscopy time (4.0 min [0.0, 11.0] and 8.0 [3.0, 17.0], respectively [p&lt;0.0001]) and irrigation fluid volume (378.0 mL [310.0, 466.0] and 636.0 [476.0, 829.0], respectively [p&lt;0.0001]) (values given as Median [Q1, Q3]), see Figure 1. Both HSP and LSP subjects had a low rate of repeat procedures (1.6% [3/182] and 4.3% [5/115], respectively [p=0.2684]) and primary safety endpoint events (4.8% [9/189] and 4.2% [5/119], respectively [p=0.8182]) through 90 days post-index procedure.

Conclusion

The acute data on the TactiFlex SE catheter demonstrates safe and effective treatment of PAF using either a HSP or LSP ablation strategy. Ablation procedures performed using a HSP strategy were shorter and required less irrigation fluid and fluoroscopy. It is anticipated these results will be reflected in the 12-month safety and effectiveness primary endpoints.

Funding Acknowledgement

Type of funding sources: Private company. Main funding source(s): Abbott

Impact of cardiovascular events on primary and hospital care costs: findings from UK Biobank study

Background

Need for primary and secondary healthcare increases following cardiovascular disease (CVD) events but there is no data on comparative increases in costs.

Purpose

To estimate annual primary care and hospital inpatient costs associated with key CVD and other adverse events using the UK Biobank (UKB) individual participant data.

Methods

UKB participants with linked primary care data (192,983 participants) or hospital inpatient episodes data (all 501,807 participants) contributed data to this study. The three categories of primary care services (patient consultations, diagnostic and monitoring tests, prescription medications), and hospital episodes were costed (2020 UK£) using the NHS England reference costs. Annual primary care costs and, separately, annual hospital inpatient costs were modelled as functions of participant characteristics at entry (socio-demographic, clinical, prior diseases) and time-updated first occurrences of myocardial infarction, stroke, coronary revascularization, incident cancer, incident diabetes, vascular death and non-vascular death during follow-up (p-value &lt;0.01 in stepwise covariate selection). One-part generalized linear regression model (GLM) with Poisson distribution and identity link function was used for primary care costs, and two-part model was used for inpatient costs (part 1: logistic regression models probability of incurring costs; part 2: GLM with Poisson distribution and identity link function models costs conditional on incurring any). Separate models were fitted among participants with and without previous CVD at entry into UKB.

Results

Most adverse events were associated with excess primary care and hospital inpatient costs. Compared to people without previous CVD, people with previous CVD had on average larger excess primary care and hospital inpatient costs in years with myocardial infarction, stroke and vascular death; but similar excess costs in years with other events. Among both people without and with previous CVD, the excess annual primary care costs were less than 7% of the excess annual hospital inpatient costs for vascular events (Table). However, following diabetes diagnosis the excess annual primary care costs were higher than the excess annual hospital inpatient costs (Table).

Conclusions

These excess primary and hospital care costs associated with CVD events could inform assessments of interventions and policies to reduce CVD risks in UK.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): UK National Institute for Health Research (NIHR) Health Technology Assessment (HTA) Programme, UK Medical Research Council (MRC), British Heart Foundation

Cost-effectiveness of statin therapy in categories of patients in the UK

Background

Cardiovascular disease (CVD) mortality has declined steadily over the last few decades across Europe and North America.

Purpose

To provide contemporary estimates of long-term effectiveness and cost-effectiveness of statin therapy in different categories of patients in UK.

Methods

The CTT-UKB micro-simulation model, developed using the Cholesterol Treatment Trialists' Collaboration data (CTT: 118,000 participants; 5 years follow-up), and calibrated in the UK Biobank cohort (UKB: 502,000 participants; 9 years follow-up). The model integrates parametric risk equations for incident myocardial infarction, stroke, coronary revascularization, diabetes, cancer and vascular and nonvascular death, and projects annually these endpoints and survival using patient characteristics at entry. UKB data and linked primary and hospital care data informed healthcare costs in the model (2020 UK£); 2021 UK NHS Drug Tariff informed statin costs (atorvastatin 40mg at £1.22 and 80mg at £1.68 per 28 tablets); and Health Survey for England data informed health-related quality of life in the model. Previous CTT meta-analysis, atorvastatin dose-response randomized trials, and further meta-analyses of statin trials and cohort studies informed effects of 40mg/80mg atorvastatin therapy daily on rates of incident myocardial infarction, stroke, coronary revascularization, vascular death, diabetes, myopathy and rhabdomyolysis.

The model was used to project gains in quality-adjusted life years (QALYs) and additional cost per QALY with lifetime use of atorvastatin 40mg or 80mg daily in categories of UKB participants by sex, age at statin initiation (40–49; 50–59 and 60–70 years), and 10-year CVD risk (QRISK3 risk (%): &lt;5; 5–10, 10–15, 15–20, ≥20). Further scenarios explored effects of 5-year delay of statin initiation in people under 45 years of age or stopping statin therapy at 80 years of age.

Results

Across men and women in categories by age and CVD risk, lifetime use of atorvastatin 40mg daily was associated with increases in survival by 0.44–1.69 years (0.28–1.02 QALYs), and atorvastatin 80mg daily with increases in survival of 0.45–1.87 years (0.32–1.13 QALYs; Figure 1) with gains larger among participants at higher CVD risk. Both atorvastatin 40mg and 80mg doses were in the range of cost-effective treatments with incremental cost per QALY gained with atorvastatin 40mg daily versus no statin therapy below £7200/QALY and with atorvastatin 80mg vs 40mg daily below £16000/QALY (Figure 2) across all patient categories studied. Compared to lifetime statin therapy, stopping therapy at 80 years of age substantially reduced benefits and was not cost-effective in any patient category studied. Similarly, compared to immediate initiation, 5-year delay of statin therapy in 40–45 years old patients was not a cost-effective.

Conclusions

In the UK, statin therapy remains highly cost-effective across men and women 40–70 years old, including those at 10-year CVD risk &lt;5%.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): UK National Institute for Health Research (NIHR) Health Technology Assessment (HTA) Programme, UK National Institute for Health Research (NIHR) Health Technology Assessment (HTA) Programme, UK Medical Research Council (MRC), British Heart Foundation

Benefit accrual with cardiovascular disease prevention and effects of discontinuation: a modelling study

Background

Statin therapy reduces rates of heart attacks and strokes and improves survival in people at increased cardiovascular disease (CVD) risk. However, there is some uncertainty when to start and how long to persist with statin therapy so as to optimise benefits.

Purpose

To project the accrual of benefit with statin therapy in population groups by age at therapy initiation using a newly developed micro-simulation model.

Methods

Participants without previous CVD (N=44,412) and with previous CVD (N=13,061) at entry were randomly selected from the UK Biobank cohort, ensuring sufficient representation in respective categories by age, LDL cholesterol, diabetes and 10-year CVD risk categories (QRISK3 score, for those without previous CVD only). The CTT-UKB model, a CVD micro-simulation model [1], was used to predict subsequent survival and quality-adjusted life years (QALYs) of the participants using their characteristics at entry. Treatment with atorvastatin 40mg daily was used as an example to illustrate the effect of the therapy compared to no such therapy. Scenarios include: (1) lifelong preventive therapy, (2) preventive therapy stopped at 80 years of age, and (3) delayed initiation of preventive therapy by 5 years in participants under 45 years of age.

Results

Statin treatment benefits, measured in QALYs gained, accrue over lifetime. The majority of benefits accrue later in life. Men accumulate larger benefits and earlier than women (Figure 1A). The pattern of benefits accrual is similar for participants with and without previous CVD (data not shown). The higher the participants' CVD risk, the larger and earlier the benefits, with younger participants accruing larger benefits (Figure 1B). Compared with lifelong prevention, stopping treatment at 80 years of age leads to large reductions in overall benefits, especially in women and those at lower CVD risk. For example, compared to lifelong therapy, people without previous CVD who initiate therapy in their 50s, would lose 47% of QALYs benefit (if men), 66% (if women), 73% (if with CVD risk &lt;5%), and 35% (if with CVD risk ≥20%), respectively, if they stop treatment when they reach 80 years of age. Five-year delay of statin therapy initiation in people under 45 years of age reduces their benefits by about 4% on average, though the loss is somewhat larger in people at higher CVD risk (Figure 2).

Conclusion

Benefits from lifelong cardiovascular prevention accrue over peoples' lifespan with large share of benefits accruing at older age. Stopping treatment earlier substantially reduces benefits.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): UK NationalInstitute for Health Research (NIHR) Health Technology Assessment (HTA) Programme, UK Medical Research Council (MRC), and British Heart Foundation

Discriminatory ability of gas chromatography-ion mobility spectrometry to identify patients hospitalised with COVID-19 and predict prognosis

Background

Rapid diagnostic and prognostic tests for coronavirus disease (COVID-19) are urgently required. We aimed to evaluate the diagnostic and prognostic ability of breath analysis using gas chromatography–ion mobility spectrometry (GC-IMS) in hospitalized patients with COVID-19.

Methods

Between February and May 2021, we took 1 breath sample for analysis using GC-IMS from participants who were admitted to the hospital for COVID-19, participants who were admitted to the hospital for other respiratory infections, and symptom-free controls, at the University Hospitals of Leicester NHS Trust, United Kingdom. Demographic, clinical, and radiological data, including requirement for continuous positive airway pressure (CPAP) ventilation as a marker for severe disease in the COVID-19 group, were collected.

Results

A total of 113 participants were recruited into the study. Seventy-two (64%) were diagnosed with COVID-19, 20 (18%) were diagnosed with another respiratory infection, and 21 (19%) were healthy controls. Differentiation between participants with COVID-19 and those with other respiratory tract infections with GC-IMS was highly accurate (sensitivity/specificity, 0.80/0.88; area under the receiver operating characteristics curve [AUROC], 0.85; 95% CI, 0.74–0.96). GC-IMS was also moderately accurate at identifying those who subsequently required CPAP (sensitivity/specificity, 0.62/0.80; AUROC, 0.70; 95% CI, 0.53–0.87).

Conclusions

GC-IMS shows promise as both a diagnostic tool and a predictor of prognosis in hospitalized patients with COVID-19 and should be assessed further in larger studies.

FaceBase: A Community-Driven Hub for Data-Intensive Research

The FaceBase Consortium, funded by the National Institute of Dental and Craniofacial Research of the National Institutes of Health, was established in 2009 with the recognition that dental and craniofacial research are increasingly data-intensive disciplines. Data sharing is critical for the validation and reproducibility of results as well as to enable reuse of data. In service of these goals, data ought to be FAIR: Findable, Accessible, Interoperable, and Reusable. The FaceBase data repository and educational resources exemplify the FAIR principles and support a broad user community including researchers in craniofacial development, molecular genetics, and genomics. FaceBase demonstrates that a model in which researchers "self-curate" their data can be successful and scalable. We present the results of the first 2.5 y of FaceBase's operations as an open community and summarize the data sets published during this period. We then describe a research highlight from work on the identification of regulatory networks and noncoding RNAs involved in cleft lip with/without cleft palate that both used and in turn contributed new findings to publicly available FaceBase resources. Collectively, FaceBase serves as a dynamic and continuously evolving resource to facilitate data-intensive research, enhance data reproducibility, and perform deep phenotyping across multiple species in dental and craniofacial research.

Understanding the interactive effects of dietary leucine with isoleucine and valine in the modern commercial broiler

A study was conducted to understand the relationship among dietary branched-chain amino acids (BCAA) on the performance of Ross 344 × 708 male broilers. A total of 2,592 d-old male chicks were randomly placed into 144-floor pens according to a 2³ full factorial central composite design (CCD) with 20 treatments (14 treatments and 6 center points). Each treatment consisted of varying digestible Ile:Lys (52 to 75), Val:Lys (64 to 87), and Leu:Lys (110 to 185) ratios. Birds and feed were weighed at 20 and 34 d of age to determine body weight gain (BWG), feed intake, and feed conversion ratio (FCR). At 35 d of age, feather amino acid composition and carcass characteristics were evaluated. Data were analyzed as CCD using the surface response option of JMP v. 15. Body weight gain (1,332 g; P < 0.001; R² = 0.93) and FCR (1.54; P = 0.002; R² = 0.88) were optimized at the lowest Leu:Lys ratio (110) with moderate Val:Lys (78 to 79) and Ile:Lys (65 to 66) ratios. Poorer BWG and FCR were observed as Leu:Lys ratio increased while increasing Val:Lys and Ile:Lys ratios alleviated the poor performance. Carcass (71.5%; P = 0.031; R² = 0.76) and breast yield (26.7%; P < 0.001; R² = 0.96) were maximized at the highest Leu:Lys ratio. This effect was complemented by increasing Ile:Lys ratio beyond 68. Lower Ile:Lys and Val:Lys ratios were required to maximize carcass and breast yield at the lowest Leu:Lys ratio. However, this strategy yielded less meat than providing a high Leu:Lys ratio diet. Dietary BCAA had little effect on altering the composition of feather protein and amino acid (P > 0.10). These results suggest that optimum BCAA ratios to Lys may vary depending on response criteria and demonstrate the importance of maintaining proper Val and Ile ratios centered on dietary Leu. Live performance can be optimized in diets with low Leu:Lys ratios; however, meat yield can be enhanced by increasing dietary Leu:Lys along with Ile:Lys ratios.

Evaluation of prognostic risk models for postoperative pulmonary complications in adult patients undergoing major abdominal surgery: a systematic review and international external validation cohort study

BACKGROUND

Stratifying risk of postoperative pulmonary complications after major abdominal surgery allows clinicians to modify risk through targeted interventions and enhanced monitoring. In this study, we aimed to identify and validate prognostic models against a new consensus definition of postoperative pulmonary complications.

METHODS

We did a systematic review and international external validation cohort study. The systematic review was done in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. We searched MEDLINE and Embase on March 1, 2020, for articles published in English that reported on risk prediction models for postoperative pulmonary complications following abdominal surgery. External validation of existing models was done within a prospective international cohort study of adult patients (≥18 years) undergoing major abdominal surgery. Data were collected between Jan 1, 2019, and April 30, 2019, in the UK, Ireland, and Australia. Discriminative ability and prognostic accuracy summary statistics were compared between models for the 30-day postoperative pulmonary complication rate as defined by the Standardised Endpoints in Perioperative Medicine Core Outcome Measures in Perioperative and Anaesthetic Care (StEP-COMPAC). Model performance was compared using the area under the receiver operating characteristic curve (AUROCC).

FINDINGS

In total, we identified 2903 records from our literature search; of which, 2514 (86·6%) unique records were screened, 121 (4·8%) of 2514 full texts were assessed for eligibility, and 29 unique prognostic models were identified. Nine (31·0%) of 29 models had score development reported only, 19 (65·5%) had undergone internal validation, and only four (13·8%) had been externally validated. Data to validate six eligible models were collected in the international external validation cohort study. Data from 11 591 patients were available, with an overall postoperative pulmonary complication rate of 7·8% (n=903). None of the six models showed good discrimination (defined as AUROCC ≥0·70) for identifying postoperative pulmonary complications, with the Assess Respiratory Risk in Surgical Patients in Catalonia score showing the best discrimination (AUROCC 0·700 [95% CI 0·683-0·717]).

INTERPRETATION

In the pre-COVID-19 pandemic data, variability in the risk of pulmonary complications (StEP-COMPAC definition) following major abdominal surgery was poorly described by existing prognostication tools. To improve surgical safety during the COVID-19 pandemic recovery and beyond, novel risk stratification tools are required.

FUNDING

British Journal of Surgery Society.

The COVANOS trial - insight into post-COVID olfactory dysfunction and the role of smell training

BACKGROUND

Olfactory dysfunction is a cardinal symptom of COVID-19 infection, however, studies assessing long-term olfactory dysfunction are limited and no randomised-controlled trials (RCTs) of early olfactory training have been conducted.

METHODOLOGY

We conducted a prospective, multi-centre study consisting of baseline psychophysical measurements of smell and taste function. Eligible participants were further recruited into a 12-week RCT of olfactory training versus control (safety information). Patient-reported outcomes were measured using an electronic survey and BSIT at baseline and 12 weeks. An additional 1-year follow-up was open to all participants.

RESULTS

218 individuals with a sudden loss of sense of smell of at least 4-weeks were recruited. Psychophysical smell loss was observed in only 32.1%; 63 participants were recruited into the RCT. The absolute difference in BSIT improvement after 12 weeks was 0.45 higher in the intervention arm. 76 participants completed 1-year follow-up; 10/19 (52.6%) of participants with an abnormal baseline BSIT test scored below the normal threshold at 1-year, and 24/29 (82.8%) had persistent parosmia.

CONCLUSIONS

Early olfactory training may be helpful, although our findings are inconclusive. Notably, a number of individuals who completed the 1-year assessment had persistent smell loss and parosmia at 1-year. As such, both should be considered important entities of long-Covid and further studies to improve management are highly warranted.

Are SER-II Ankle Fractures Anatomic? Computed Tomography Demonstrates Mortise Malalignment in the Setting of Apparently Normal Radiographs

BACKGROUND

Ankle fracture treatment is predicated on minimal displacement, leading to abnormal joint contact area. The purpose of this investigation is to determine whether computed tomography (CT) detects subtle mortise malalignment undetectable by x-ray in supination-external rotation-II (SER-II) injuries.

METHODS

A total of 24 patients with SER-II injuries, as demonstrated by negative gravity stress radiography, were included. Medial clear space (MCS) measurements were performed on bilateral ankle x-rays (injured and contralateral, uninjured side) at several time points as well as bilateral non-weight-bearing CT performed once clinical and radiographic healing was demonstrated (mean = 66 days post injury, range = 61-105 days). Statistical analyses examined differences in measurements between both sides.

RESULTS

Final x-rays demonstrated no differences between normal and injured ankle MCS (P = .441). However, CT coronal/axial MCS measurements were different (P < .05). CT coronal MCS measured wider by a mean difference of 0.67 mm (P < .001).

CONCLUSION

There is a high incidence of subtle mortise malalignment in SER-II ankle fractures, as demonstrated by CT, which is undetectable when assessed by plain radiographs. Although clinical outcomes are yet unknown, there are important implications of the finding of confirmed, subtle mortise malalignment in SER-II injuries and the limitations of x-ray to detect it.

LEVEL OF EVIDENCE

Level III.

Acute results of a novel flexible tip radiofrequency catheter incorporating contact force sensing

Funding Acknowledgements

Type of funding sources: Private company. Main funding source(s): Abbott

Background

Catheter ablation is an established therapy for paroxysmal atrial fibrillation (PAF). The TactiFlex Ablation Catheter, Sensor-Enabled (TactiFlex SE) is a next-generation radiofrequency ablation catheter incorporating highly accurate fiber optics-based contact force sensing technology with a flexible, laser-cut tip. This is the first report of results from the TactiFlex IDE clinical study.

Purpose

To demonstrate that ablation with TactiFlex SE is safe and effective for the treatment of drug refractory, symptomatic PAF.

Methods

The TactiFlex IDE (NCT04356040) is a prospective, non-randomized, multi-center clinical study which enrolled 305 subjects worldwide in the main study. Enrollment in the main study began on June 26, 2020 and completed on June 8, 2021. Subjects underwent de novo Pulmonary Vein Isolation (PVI) and, if indicated, a Cavotricuspid Isthmus ablation (CTI line) for CTI-dependent atrial flutter.

Results

Acute procedural success was achieved in 98.6% (274/278) of the main study cohort who underwent an ablation procedure using the TactiFlex SE. First pass success, defined as isolation of all pulmonary veins (PVs) confirmed after a minimum 20 min waiting period was achieved in 89.6% (249/278) of subjects. This was a significant improvement versus the TactiSense IDE trial (TactiCath Ablation Catheter, Sensor-Enabled). Significant decreases were also seen in total procedure time (123 min [101.0, 163.5]), total PV ablation time (55.5 min [35.0, 81.0]), total fluoroscopy time (6.0 min [0.0, 13.0]) and irrigation fluid volume (450.0 mL [346.0, 636.0]) (values given as Median [Q1, Q3]), see FIGURE. All subjects have completed at least 90 days of follow-up. Only 2.6% (7/271) of subjects required a repeat procedure during the 90-day blanking period. The primary safety and effectiveness endpoints will be evaluated at 12-months. At 90 days, 4.3% (12/281) subjects had experienced a primary safety endpoint event.

Conclusions

The acute data from the TactiFlex IDE clinical study demonstrate safety and effectiveness of the TactiFlex SE catheter in the treatment of PAF. Ablation procedures performed using the next-generation TactiFlex SE catheter were shorter and had improved acute clinical effectiveness outcomes versus the TactiSense IDE. It is anticipated these results will also be reflected in the 12-month safety and effectiveness endpoints.

High-density mapping in catheter ablation for persistent atrial fibrillation

Funding Acknowledgements

Type of funding sources: Private company. Main funding source(s): Abbott Laboratories

Background

Pulmonary vein isolation (PVI) is an established treatment option for persistent atrial fibrillation (PersAF). Corresponding long-term success rates remain modest however, advancements in high-density (HD) mapping may better identify substrates. The HD grid-style mapping catheter (HD Grid) allows for simultaneous analysis of adjacent orthogonal bipolar signals that may assist in ablation strategy decisions to achieve favorable outcomes in treating PersAF.

Objective

This was a prospective, multi-center, observational study to quantify and characterize the use of a market-released HD mapping catheter in PersAF subjects.

Methods

HD Grid was used in PersAF subjects undergoing radiofrequency (RF) ablation across 25 sites to gather data regarding safety, mapping efficiency and quality, ablation strategies, and procedural outcomes.

Results

334 PersAF subjects (average age: 64.2 years; 76% male) were enrolled in this study. Types of maps generated included peak-to-peak voltage (78%; 322/413), local activation time (LAT) (11.4%; 47/413), and complex fractionated electrogram (CFE) mean (7.7%; 32/413). Median total mapping points collected and used were 8428.0 (IQR 4845.0-13366.0) and 2099.0 (IQR 1219.0-2947.0), respectively, in a median of 11.0 (IQR 7.3-16.0) minutes per map. Low voltage, scar/fibrosis, and CFE were searched for in 90.4% (302/334), 53.6% (179/334), and 15.9% (53/334) of subjects, respectively. A PVI approach was used in 93.1% of all ablation procedures and 34.1% (114/334) of subjects received PVI plus additional lesions. HD Grid identified signals of interest not identified by the ablation catheter in 80.4% (205/255) of subjects. The total procedure time was 134.3 ± 51.3 minutes with a fluoroscopy time of 14.5 ± 11.3 minutes and RF ablation time of 32.4 ± 29.6 minutes. Of the subjects in atrial fibrillation (AF) (59.6%; 199/334), AF was terminated in 80.4% (160/199). 87.4% (173/198) of subjects were free from recurrent atrial arrhythmias as detected by 48-hour Holter monitoring at 12 months. 13.8% (46/334) of subjects experienced any adverse event through 12 months including 1 death unrelated to the procedure and 1 event deemed related to HD Grid by the investigator.

Conclusion

This study demonstrated the use of the HD Grid mapping catheter to create detailed maps and to guide ablation strategies to treat PersAF while maintaining an adequate safety profile.

Inhibition of Streptococcus pneumoniae growth by masarimycin

Despite renewed interest, development of chemical biology methods to study peptidoglycan metabolism has lagged in comparison to the glycobiology field in general. To address this, a panel of diamides were screened against the Gram-positive bacterium Streptococcus pneumoniae to identify inhibitors of bacterial growth. The screen identified the diamide masarimycin as a bacteriostatic inhibitor of S. pneumoniae growth with an MIC of 8 µM. The diamide inhibited detergent-induced autolysis in a concentration-dependent manner, indicating perturbation of peptidoglycan degradation as the mode-of-action. Cell based screening of masarimycin against a panel of autolysin mutants, identified a higher MIC against a ΔlytB strain lacking an endo-N-acetylglucosaminidase involved in cell division. Subsequent biochemical and phenotypic analyses suggested that the higher MIC was due to an indirect interaction with LytB. Further analysis of changes to the cell surface in masarimycin treated cells identified the overexpression of several moonlighting proteins, including elongation factor Tu which is implicated in regulating cell shape. Checkerboard assays using masarimycin in concert with additional antibiotics identified an antagonistic relationship with the cell wall targeting antibiotic fosfomycin, which further supports a cell wall mode-of-action.

Social determinants of health influence disease activity and functional disability in Polyarticular Juvenile Idiopathic Arthritis

BACKGROUND

Social determinants of health (SDH) greatly influence outcomes during the first year of treatment in rheumatoid arthritis, a disease similar to polyarticular juvenile idiopathic arthritis (pJIA). We investigated the correlation of community poverty level and other SDH with the persistence of moderate to severe disease activity and functional disability over the first year of treatment in pJIA patients enrolled in the Childhood Arthritis and Rheumatology Research Alliance Registry.

METHODS

In this cohort study, unadjusted and adjusted generalized linear mixed effects models analyzed the effect of community poverty and other SDH on disease activity, using the clinical Juvenile Arthritis Disease Activity Score-10, and disability, using the Child Health Assessment Questionnaire, measured at baseline, 6, and 12 months.

RESULTS

One thousand six hundred eighty-four patients were identified. High community poverty (≥20% living below the federal poverty level) was associated with increased odds of functional disability (OR 1.82, 95% CI 1.28-2.60) but was not statistically significant after adjustment (aOR 1.23, 95% CI 0.81-1.86) and was not associated with increased disease activity. Non-white race/ethnicity was associated with higher disease activity (aOR 2.48, 95% CI: 1.41-4.36). Lower self-reported household income was associated with higher disease activity and persistent functional disability. Public insurance (aOR 1.56, 95% CI 1.06-2.29) and low family education (aOR 1.89, 95% CI 1.14-3.12) was associated with persistent functional disability.

CONCLUSION

High community poverty level was associated with persistent functional disability in unadjusted analysis but not with persistent moderate to high disease activity. Race/ethnicity and other SDH were associated with persistent disease activity and functional disability.

A139 EQUITY IN ACCESS TO COLORECTAL CANCER SCREENING IN NOVA SCOTIA

Background

Population-based colorectal cancer (CRC) screening programs aim to minimize inequities in participation through universal access, however, there remain disparities associated with low education, socio-economic status, and population centre. In the United States racialized groups have lower screening participation, and Black and Indigenous adults have higher CRC mortality. There is no Canadian data on racialized group participation in CRC screening because racial and ethnic data is not routinely collected. The Nova Scotia Colon Cancer Prevention Program (NSCCPP) mails fecal immunochemical tests (FIT) biennially to all residents aged 50–74 and allows for optional self-identified race and ethnicity.

Aims

To determine whether participation rates in the NSCCPP differ on the basis of race/ethnicity, age, sex, or population centre. In this preliminary analysis we report screening participation on the basis of race/ethnicity.

Methods

A retrospective cohort study was performed using the NSCCPP database to identify screen-eligible adults who returned a FIT to the program (i.e. participated) from 2011 to 2021. Racialized groups were identified based on self-identification form results allowing for multiple category selections. Race/Ethnicity was categorized as White, Black/African Canadian, Indigenous, Asian, Middle Eastern. The 2016 Canadian census was used to estimate the screen-eligible population (age 50–74) and race/ethnicity group population sizes. Unique participants were identified as individuals who returned one or more FITs in the study period. Unique participants were compared to the screen-eligible population to estimate participation over the 10-year study period.

Results

508,533 FITs were returned over 10 years by 208,702 unique participants. The number of annual FITs returned ranged from 14,066 in 2011 to 65,746 in 2019. Participants were 56% female, 44% male, with a mean age 62.8 (± 7.0). FIT status was 89% negative, 7% positive, and 4% indeterminate. 96% (n=490,398) of participants provided self-identification data. Table 1 provides the screen-eligible population, unique participants, and FIT participation over the 10-year study period all characterized by race/ethnicity. Over 10 years, 59% of the eligible population participated in CRC screening by returning at least one FIT.

Conclusions

CRC screening participation by race/ethnicity in Canada is unknown. This analysis of the NSCCPP suggests that participation by racialized individuals including Black/African Canadian, Asian, and Indigenous, are lower relative to White individuals. Further analyses will explore race/ethnicity and gender in terms of temporal and geographic trends.

Table 1.

Funding Agencies

None

Barriers and facilitators to targeted anxiety prevention programmes in families at risk: a qualitative interview study

Anxiety disorders are the most common psychiatric disorder in children and young people. They can be prevented in those at risk, but families do not always take up opportunities to participate in prevention programmes. This qualitative study aimed to understand what families with children who were at prospective risk of anxiety disorders perceived to be the barriers to access to targeted anxiety prevention programmes, and to explore what would help facilitate access. We used Information Power to determine our sample size, and individually interviewed seven young people (14-17 years) who had anxiety disorders and their mothers, each of whom had pre-natal anxiety disorders. We transcribed all interviews and thematically analyzed them to identify perceived barriers and facilitators to targeted anxiety prevention programmes. Perceived potential barriers to access included possible negative consequences of anxiety prevention, difficulties in identifying anxiety as a problem and concerns about how professions would respond to raising concerns about anxiety. Possible facilitators included promoting awareness of anxiety prevention programmes and involvement of schools in promotion and delivery of prevention. Our findings illustrate that implementation of targeted anxiety prevention could be improved through (i) the provision of tools for parents to recognize anxiety in their children as a problem, (ii) promotion of awareness, as well as delivery, of anxiety prevention via schools and (iii) the involvement of parents and possibly adolescents in the intervention programme, but not younger children.

Anatomic and Radiographic Safe Zone for Posterior Malleolar Screw Placement

BACKGROUND

The most appropriate treatment and management of posterior malleolar fractures (PMFs) lacks consensus. Indirect reduction and fixation with posterior to anterior (PA) screw shows promise by avoiding the risks associated with direct reduction or indirect anterior to posterior approaches. Some authors have raised concerns about potential risk to nearby structures with the PA technique, including hardware prominence into the syndesmosis. This study highlights use of the posteromedial vertical syndesmotic line (PVSL) as a fluoroscopic landmark, helping surgeons avoid intrasyndesmotic placement. Study aims are to evaluate PVSL correspondence with posterior border of the incisura tibialis and to define a safe zone between this line and flexor hallucis longus tendon.

METHODS

Indirect PA screw placement was completed on 10 cadaveric specimens, followed by fluoroscopy in mortise and lateral views. Dissection was performed to assess screw placement relative to the posteromedial border of the syndesmosis. The posterior border of the syndesmosis was marked with a radiopaque wire. Repeat imaging was completed to validate the fluoroscopic PVSL is representative of the posteromedial border of the tibial incisura.

RESULTS

On dissection, 9 out of 10 cadavers had accurate screw placement with no penetration into the syndesmosis. Corresponding imaging showed the screw head to be medial to the marker on mortise view. For the specimen with penetration into the syndesmosis, imaging confirmed that the screw head was lateral to the marker on mortise views. The radiopaque marker correlated with the PVSL for all specimens when comparing anatomic to radiographic findings. A radiographic safe zone is defined for the PA screw 12 mm medial to the PVSL to ensure no iatrogenic injury to the flexor hallucis longus tendon.

CONCLUSION

This study demonstrated that a posterior incisura tibialis fluoroscopic landmark is unambiguous in localizing the posterior syndesmotic border and that screws medial to this line are safely out of the syndesmosis, while screws placed lateral are either in or at risk of intrasyndesmotic placement. A safe zone is defined for screw placement.

CLINICAL RELEVANCE

This article describes a radiographic and clinical safe zone for fixation and hardware placement during open reduction internal fixation (ORIF) of PMFs. This information will assist surgeons in avoiding intrasyndesmotic hardware placement as well as injury to deep soft tissue structures.

Evidence-Based Determination of Cut-Off Points for Increased Cardiac-Surgery Mortality Risk With EuroSCORE II and STS: The Best-Performing Risk Scoring Models in a Single-Centre Australian Population

OBJECTIVES

Risk scoring models (RSMs) are commonly used for estimation of postoperative-mortality risk in patients undergoing cardiac surgery, but their prediction accuracy may vary in different populations and clinical situations. The prognostic accuracies of some RSMs have not yet been fully evaluated in the Australian population. In this retrospective observational study, our aims were to assess the performance of four contemporary RSMs, to identify the best RSMs for prediction of postoperative-mortality in the single-centre cohort, and to determine a statistical threshold for classification of patients with increased or "higher" mortality risk.

METHODS

The study population included patients who underwent cardiac surgery at Liverpool Hospital between January 2013 and December 2014. Demographic information was collected, and mortality risks were estimated with the ES2 (EuroSCORE II), STS (Society of Thoracic Surgeons Score), AS (AusSCORE total) and ASMR (AusSCORE multi-risk) RSMs. (Additive EuroSCORE) (AES) and LES (logistic EuroSCORE) were included for historical interest. Discrimination, the ability to stratify patients between mortality and no mortality outcomes, and calibration, the comparison of risk score estimated and observed outcome in the population, were evaluated for each RSM, to determine their predictive accuracy in the study population. Discrimination was assessed by the AUC (area under the receiver operating characteristic curve), and acceptable calibration by the p-value greater than 0.05 for the Hosmer-Lemeshow (H-L) test. The best AUCs in contempory models were compared using the DeLong test. For ES2 and STS risk scores, cut-off points, or thresholds, for patients at increased risk of mortality were derived using Youden's J-statistics, calculated from sensitivity and specificity of models in predicting mortality.

RESULTS

From a total study population of 898 patients, 738 had scores for all six RSMs. The three EuroSCORE risk models and Youden's J-statistics analysis included the total population. Of the models in contemporary use, ES2 had higher discrimination (AUC=0.850) in this population than ASMR (AUC=0.767, p=0.024) and AS (AUC=0.739) and non-significantly higher discrimination than STS (AUC=0.806, p=0.19). All contemporary models had acceptable calibration but the older LES (H-L p=0.024) did not. Estimated mortality was closest to observed mortality with the ES2 model. Both AES and LES over predicted mortality. The RSM with the highest discrimination in isolated coronary artery bypass graft surgery (CAGs) (AUC=0.847), isolated valves (AUC=0.830), and females (AUC=0.784) was the ES2 model. STS discrimination was highest in CAGs plus valve procedures (AUC 0.891), and males (STS AUC=0.891). Cut-off points for risk scores to define increased risk populations were 3.0% for ES2 and 1.7% for STS. Similar proportions of patients in each RSM (ES2-26% to STS-32%) were defined as higher risk by the model threshold score depending on type of procedure.

CONCLUSION

Among RSMs in contemporary use, ES2 and STS showed the best discrimination and acceptable calibration. Caution is recommended in specific subgroups. Increased mortality risk score cut-off points could be identified for these two RSMs in this single-centre cohort.

A model of lifetime health outcomes in cardiovascular disease based on clinical trials and large cohorts

Background and purpose

Cardiovascular disease (CVD) risk of individuals depends on their socio-demographic characteristics, clinical risk factors, and treatments, and strongly influences their quality of life and survival. Individual-based long-term disease models, which aim to more accurately calculate the lifetime consequences, can help to target treatments, develop disease management programmes, and assess the value of new therapies. We present a new micro-simulation CVD model.

Methods

This micro-simulation model was developed using individual participant data from the Cholesterol Treatment Trialists' collaboration (CTT: 118,000 participants; 15 trials) and calibrated (with added socioeconomic deprivation, ethnicity, physical activity, mental illness, cancer and incident diabetes) in the UK Biobank cohort (UKB: 502,000 participants). Parametric survival models estimated risks of key endpoints (myocardial infarction (MI), stroke, coronary revascularisation (CRV), diabetes, cancer and vascular (VD) and nonvascular death (NVD) using participants' age, sex, ethnicity, physical activity, socioeconomic deprivation, smoking history, lipids, blood pressure, creatinine, previous cardiovascular diseases, diabetes, mental illness and cancer at entry and non-fatal incidents of the key endpoints during follow-up. The model integrates the risk equations and enables annual projection of endpoints and survival over individuals' lifetimes. The model was used to project remaining life expectancy across UK Biobank participants.

Results

Nonfatal cardiovascular events and age were the major determinants of CVD risk and, together with incident diabetes and cancer, of individuals' survival. The cumulative incidence of the key endpoints predicted by the CTT-UKB model corresponded well to their observed incidence in the UK Biobank cohort, overall (Figure 1) and in categories of participants by age, sex, prior CVD and CVD risk. Predicted remaining life expectancy across UK Biobank participants without history of CVD ranged between 22 and 43 years in men and between 24 and 46 years in women, depending on their age and CVD risk (Figure 2). Among UK Biobank participants with history of CVD, depending on their age, predicted remaining life expectancy ranged from 20 to 32 years in men and from 26 to 38 years in women.

Conclusion

This new lifetime CVD model accurately predicts morbidity and mortality in a large UK population cohort. It will be made available to provide individualised projections of expected lifetime health outcomes and benefits of treatments.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): UK National Institute for Health Research (NIHR) Health Technology Assessment (HTA) Programme, UK Medical Research Council (MRC), British Heart Foundation Figure 1. Predicted (in black) versus observed (95% CI; in red) incidence of major clinical outcomes in the UK Biobank.Figure 2. Predicted remaining life expectancy of participants in UK Biobank cohort, by age and CVD risk or previous CVD at entry. QRISK, a 10-year CVD risk scoring algorithm for people without previous CVD, recommended for use in the UK National Health Service.

Impact of adverse events on quality of life and hospital costs in secondary cardiovascular disease prevention

Background and purpose

People with atherosclerotic vascular disease remain at high risk of cardiovascular (CVD) events despite effective risk factor management 1. There is little research on impacts of adverse events on quality of life (QoL) and hospital cost to inform evaluations of novel interventions in this population. We estimate QoL and annual hospital costs associated with a range of adverse events of interests using the individual participant data from the Randomized Evaluation of the Effects of Anacetrapib through Lipid Modification (REVEAL) trial.

Methods

Data from the 30,449 participants with atherosclerotic vascular disease receiving effective statin therapy in REVEAL, were used to estimate regression models for participants' hospital costs and QoL using participants' characteristics at entry (socio-demographic, clinical, prior diseases and treatments) and time-updated adverse events. We estimate costs and QoL in the year of an event, and in subsequent years, using stepwise covariate selection (p-value &lt;0.01). Standard errors were adjusted for clustering of participant annual costs.

Hospital episodes were costed (2019 UK£) using the UK Healthcare Resource Groups reference costs 2. One- and two-part generalized linear regression models (GLMs) for annual hospital costs (part 1: logistic model for estimating probability of incurring cost, part 2: GLM with Gaussian, Poisson or Gamma distributions with identity or log links for estimating costs, conditional on incurring any) were compared.

EQ-5D-5L questionnaires, completed by study participants at entry and final follow-up visits in the study, were mapped into QoL utility scores 3. QoL utility at final follow-up was used to estimate QoL decrements of adverse events using GLM linear model and adjusting for QoL at entry in addition to other participants characteristics.

Results

The two-part model with gamma distribution and identity link, indicated by specification tests and model fit statistics, was selected for modelling annual hospital costs (Figure 1). Non-haemorrhagic stroke, non-coronary revascularization, coronary revascularization and incident cancer were associated with highest hospital costs. The QoL model (Figure 2) indicated large QoL decrements associated with non-fatal non-haemorrhagic stroke, heart failure hospitalization, incident cancer and non-coronary revascularization, and comparatively small QoL decrement associated with experiencing non-fatal myocardial infarction.

Conclusion

These cost and QoL models in a well-managed contemporary high CVD risk patient population would assist in assessments of long-term net effects and cost-effectiveness of novel interventions to reduce cardiovascular risk.

Funding Acknowledgement

Type of funding sources: Other. Main funding source(s): Merck Sharp & Dohme and UK Medical Research Council Figure 1Figure 2

3-D generated anatomic custom talar cement spacers: case reports, technical tips and literature review

Background

With today’s expanding use of total ankle arthroplasty, the ever-present trauma patient, and patients with uncontrolled comorbid conditions, surgeons face significant challenges for lower extremity reconstruction. These patients highlight some of those who may present with unique anatomy, bone loss, infection, and various other local and systemic factors that affect treatment options for successful outcomes. Three dimensional (3-D) printing for medical devices is allowing for new and customized ways to meet patient and surgeon goals of limb salvage and reconstruction.

Case presentations

While the majority of 3-D printing is done for the purpose of implantation, we present a technical tip for designing a 3-D printed mold from which to create an antibiotic cement spacer for implantation. With two case illustrations including a talus fracture nonunion and infected subtalar arthrodesis nonunion, we describe the process of patient selection, implant design, fabrication, and implantation of a custom molded antibiotic cement talus.

Discussion

Case illustrations present two successful limb salvage patients while giving a thorough explanation of our technique, learned tips and tricks. This applied technology builds on prior use of antibiotic cement in limb salvage of the lower extremity, most of which are joint sacrificing. 3-D printing the mold for an anatomic talus cement spacer results in a joint sparing limb salvage solution.

Innovative 3-D printing technology is merged with current, pertinent literature regarding antibiotic cement to offer surgeons expanded options for temporary or definitive reconstructive techniques in some of the most challenging patients.

Contamination of the Mini C-Arm During Foot and Ankle Surgery

BACKGROUND

Many orthopedic surgeries utilize intraoperative fluoroscopy. The mini C-arm is an advantageous device as it can be easily used without the need for a dedicated radiology technician. However, there are concerns that the mini C-arm may represent a potential source of contamination and subsequent postoperative infection. Previous investigations of standard C-arm drapes have shown high rates of contamination. Similar contamination rates would be even more concerning for the mini C-arm as it requires physically maneuvering the machine. This study aimed to determine the rate of mini C-arm drape contamination and identify high-risk areas.

METHODS

Fifty foot and ankle surgeries requiring the use of mini C-arm fluoroscopy were included. Eight locations on the mini C-arm drape were sampled at the conclusion of each procedure. Culture Q-swabs were used for sampling defined locations. Swab samples were then assessed for bacterial growth on a 5% blood agar plate using a semiquantitative technique.

RESULTS

In 70% of surgical cases, contamination was observed in at least 1 location. Six of the 8 evaluated locations were found to have significantly higher contamination in comparison with their corresponding negative controls (Mann-Whitney U test, P < .05). The "outer portion of the upper arm" (location 1) exhibited bacteria growth in 26% (P < .0001) of cases. The "superior portion of the x-ray source" (location 2) exhibited growth in 30% (P < .0001) of cases. These were the highest-risk areas for contamination and were both significantly more likely to be involved than the "inferior portion of the x-ray source" and "superior portion of the beam receiver," locations 4 and 5, respectively. Fourteen percent (7/50) C-arm cases and 1.72% (1/58) Achilles tendon surgery control cases developed surgical site infection (P = .0234; OR, 9.27).

CONCLUSION

Bacterial contamination of the mini C-arm drape was found to be common after foot and ankle procedures. Contamination was more prevalent on the outer ring areas of the C-arm, both at the emitter and receiver.

LEVEL OF EVIDENCE

Level III, prospective cohort study.

An epidemiological investigation of COVID-19 outbreaks in a group of care homes in Wales, UK: a retrospective cohort study

Background

This study describes the epidemiology of COVID-19 outbreaks in four care homes in terms of spread, severity, presentation and interventions.

Methods

Participants were 100 residents and 102 staff from four co-located care homes in Wales. Data were collected from the homes and Public Health Wales, including demographics, presentations, test status and results, hospital admissions and deaths. Genomic sequencing of confirmed case samples was completed, where possible. Epi-curves, crude attack rates, a Kaplan-Meier survival curve and adjusted hazard ratios were calculated using R.

Results

About 14 confirmed and 43 possible resident cases, 23 confirmed and 47 possible staff cases occurred. Crude attack rates of possible and confirmed cases were 57% (residents) and 69% (staff). Genomic sequencing for 10 confirmed case PCR samples identified at least 5 different UK lineages of COVID-19.42 (42%) residents died, 23 (55%) with COVID-19 or suspected COVID-19 recorded on the death certificate. The hazard ratio for death amongst resident possible and confirmed cases compared to null cases, adjusting for age and sex, was 13.26 (95% CI 5.61–31.34).

Conclusions

There were extensive outbreaks of COVID-19 in these homes with high crude attack rates and deaths. Universal testing and early isolation of residents are recommended.

538 Patient Satisfaction from ENT Phone Consultations During COVID-19

Introduction

Telephone consultations (TCs) have rapidly increased in the outpatient setting due to the coronavirus pandemic. We have implemented a quality improvement project to improve patient satisfaction of TCs in our unit.

Method

This was a prospective complete-cycle project, with online patient satisfaction questionnaires sent following TCs in ENT clinics. This consisted of 28 questions including the Medical Interview Satisfaction Scale (MISS-21).

Based on results and a current literature review, a two-pronged intervention was designed, comprising of staff education and application of a model structured TC framework. A follow-up survey was subsequently undertaken.

Results

100 patient questionnaires were collected (April & June 2020). Significant improvements in MISS-21 scores were seen over the two surveys (p = 0.026). An average MISS-21 score of 114.6 (range 49 – 147) was seen in the first survey, with a mean score of 128.5 (range 79 – 142) seen in the second (maximum score of 147). There was a significantly increased preference for TC over FTF appointments over the two surveys (p = 0.021).

Conclusions

We have shown significant improvements in patient satisfaction and an increased TC preference through use of a structured consultation model. Its potential benefits in infection control and impact on outpatient workload may see TCs persist in the post-coronavirus era.