Interactions between chromium species and DNA in vitro and their potential role in the toxicity of hexavalent chromium

Epidemiological and animal studies have supported the carcinogenicity of hexavalent chromium [Cr(VI)]; however, molecular changes responsible for the induction of cancer by Cr(VI) are not entirely understood. Numerous mechanistic studies suggested the role of oxidative stress and genotoxicity in Cr(VI)-mediated carcinogenesis; however, specific types of DNA damage have not yet been conclusively attributed to specific chromium species or other reactive byproducts generated in biological systems exposed to Cr(VI). Due to the remarkably complex chemistry and biological effects of chromium species generated through the intracellular reduction of Cr(VI), their relevance for Cr(VI)-mediated carcinogenesis has not yet been fully elucidated and continues to be a subject of ongoing discussions in the field. In this report, we describe a complex world of chromium species and their reactivity with DNA and other biologically relevant molecules in vitro to inform a more complete understanding of Cr(VI)-mediated toxicity. In addition, we discuss previous results in the context of in vitro models and analytical methods to reconcile some conflicting findings on the biological role of chromium species.

Laboratory performance of genome-wide cfDNA for copy number variants as compared to prenatal microarray

BACKGROUND

Noninvasive prenatal testing (NIPT) allows for screening of fetal aneuploidy and copy number variants (CNVs) from cell-free DNA (cfDNA) in maternal plasma. Professional societies have not yet embraced NIPT for fetal CNVs, citing a need for additional performance data. A clinically available genome-wide cfDNA test screens for fetal aneuploidy and CNVs larger than 7 megabases (Mb).

RESULTS

This study reviews 701 pregnancies with "high risk" indications for fetal aneuploidy which underwent both genome-wide cfDNA and prenatal microarray. For aneuploidies and CNVs considered 'in-scope' for the cfDNA test (CNVs ≥ 7 Mb and select microdeletions), sensitivity and specificity was 93.8% and 97.3% respectively, with positive and negative predictive values of 63.8% and 99.7% as compared to microarray. When including 'out-of-scope' CNVs on array as false negatives, the sensitivity of cfDNA falls to 48.3%. If only pathogenic out-of-scope CNVs are treated as false negatives, the sensitivity is 63.8%. Of the out-of-scope CNVs identified by array smaller than 7 Mb, 50% were classified as variants of uncertain significance (VUS), with an overall VUS rate in the study of 2.29%.

CONCLUSIONS

While microarray provides the most robust assessment of fetal CNVs, this study suggests that genome-wide cfDNA can reliably screen for large CNVs in a high-risk cohort. Informed consent and adequate pretest counseling are essential to ensuring patients understand the benefits and limitations of all prenatal testing and screening options.

Prenatal screening for preeclampsia: the roles of PlGF and PAPP-A in the first trimester and PlGF and SFlt-1/PlGF ratio in the early second trimester

BACKGROUND

Professional societies have recommended universal first trimester screening for preeclampsia and a second or third trimester soluble fms-like tyrosine kinase-1-placental growth factor ratio test to assess for preeclampsia and its severity. However, it may not be feasible to implement the most optimal screening protocol for preeclampsia in the first trimester which uses a combination of maternal characteristics, maternal biophysical and biochemical markers due to limitations in the access to uterine artery doppler ultrasound. There are inconsistent findings on how early in the second trimester the fms-like tyrosine kinase-1-placental growth factor ratio begins to provide useful information in preeclampsia prediction.

OBJECTIVE

This study aimed to assess the accuracy of (1) a combination of maternal characteristics, maternal serum pregnancy-associated plasma protein A, and placental growth factor in the screening for preeclampsia in the first trimester; and (2) placental growth factor or soluble fms-like tyrosine kinase-1-placental growth factor ratio in the prediction of preeclampsia in the early second trimester.

STUDY DESIGN

This retrospective case-control study used frozen residual blood samples from women who had aneuploidy screening and delivered at a tertiary center. The case group included pregnancies with gestational hypertension or preeclampsia (further classified as early-onset [birth at <34 weeks' gestation] and preterm preeclampsia [birth at <37 weeks' gestation]). Each case was matched with 3 control pregnancies by date of blood sample draw, gestational age at first blood sample draw, maternal age, maternal ethnicity, type of multiple-marker screening, and amount of residual sample. Mann-Whitney U tests were used to assess the associations between serum markers and the risk of preeclampsia. Logistic regressions were used to assess if the risk of preeclampsia can be predicted using a combination of maternal characteristics and serum markers.

RESULTS

The case group included 146 preeclampsia and 295 gestational hypertension cases. Compared with the controls, preeclampsia cases had significantly lower first-trimester pregnancy-associated plasma protein A and placental growth factor. At a 20% false-positive rate, 71% of early-onset and 58% of preterm preeclampsia cases can be predicted using maternal characteristics, pregnancy-associated plasma protein A, and placental growth factor. Preeclampsia cases had lower second-trimester placental growth factor and a higher soluble fms-like tyrosine kinase-1-placental growth factor ratio. At a 10% false-positive rate, 80% and 53% of early-onset preeclampsia can be predicted using maternal characteristics and placental growth factor or soluble fms-like tyrosine kinase-1-placental growth factor ratio, respectively.

CONCLUSION

The current first-trimester aneuploidy screening programs may be expanded to identify women at increased risk of developing preeclampsia. Early in the second trimester, placental growth factor alone provided better prediction for preeclampsia compared with the soluble fms-like tyrosine kinase-1-placental growth factor ratio.

113 AUDIT: DELIRIUM RECOGNITION ON AN ACUTE MEDICAL WARD

Background

One-third of older general medical patients have delirium; it is present in half of these patients on admission and develops during hospitalisation in the other half. Despite its high prevalence, delirium is frequently not recognised, evaluated or managed appropriately resulting in poor outcomes. Our aim was to assess whether or not delirium was being recognised and documented on the General Medical Wards (GMW).

Methods

We completed a prospective chart review using an audit tool on all patients aged ≥65 years on a GMW and a Specialist Geriatric Ward (SGW) over a 24-hour period. We screened all identified patients using the 4AT Test. The standard measured against was the HSE Guideline – Delirium on General Hospital Wards: Identifying Patients at Risk, Delirium Screening and Next Steps.

Results

We included 27 patients in the study (n=27) – median age was 80 years (range 65-90); 17 were male (62.96%); 10 were on a SGW (37.04%). There was a 4AT documented on 9 (n=10) of the patients on the SGW (90%) in comparison to 0 (n=17) on the GMW (0%).

We identified n=7 patients with a 4AT ≥4 consistent with acute delirium – 4 were on the SGW (57.14%). All 4 of these patients (n=4) were documented as delirious on the SGW (100%). Of the 3 patients identified on the GMW (n=3), 1 was documented as delirious (33.33%).

All patients with delirium (n=7) had non-pharmacological measures implemented (100%), most commonly catheter avoidance (100%), analgesia (100%) and regular mobilization (85.71%). Pharmacological management was administered in 2 cases (28.57%).

Conclusion

Our audit demonstrates that despite a high prevalence of delirium amongst older adults on GMWs, it remains under-recognized missing a pertinent opportunity to investigate and initiate management. This may result in adverse outcomes. The first step in improving care in older adults suffering from delirium is detection. Detection begins with screening.

240 STANDARDISING POST-FALL MEDICAL REVIEWS FOR HOSPITAL INPATIENTS

Background

Falls are the most common adverse incident of inpatients in Irish hospitals. 6% of inpatient falls cause serious injury. Older inpatients have the highest risk of falling and the highest risk of injury. The post-fall medical review is critical to assess why a patient fell, did the fall cause injury and for the introduction of measures to prevent future falls. We assessed the quality of the post fall reviews in a large hospital. We then introduced a standardised post-fall medical review pro forma and reassessed the quality of the reviews.

Methods

We reviewed 18 charts of patients that fell in hospital and assessed the documentation of the post fall review in terms of the inclusion of key elements such as patient identifiers, history, examination, injury management and future falls prevention. We then introduced a post-fall standardised pro-forma on five wards in the hospital and following this assessed 19 charts of patients who had fallen looking at the same key elements of the post fall review. We compared the quality of the post-fall review before and after the introduction of the pro forma.

Results

The post-falls medical review pro forma improved the quality of the post fall medical review. Hip Trauma: 11.1% of doctors asked about hip strike prior to proforma versus 100% who asked with the proforma. Joint examination: 50% assessed this prior to the proforma versus 100% with the pro-forma. Other aspects of the review that improved included head-strike assessment (89% versus 100%), loss of consciousness history (61% versus 95%), medication reviewed (22% versus 68%) and vital signs assessed (67% versus 95%).

Conclusion

The introduction of a standardised post fall review pro forma improves the quality of this important medical review. It is a useful aid for doctors and provides a framework to follow when reviewing the patient.

Modified multiple marker aneuploidy screening as a primary screening test for preeclampsia

Background

Abnormal levels of maternal biochemical markers used in multiple marker aneuploidy screening have been associated with adverse pregnancy outcomes. This study aims to assess if a combination of maternal characteristics and biochemical markers in the first and second trimesters can be used to screen for preeclampsia (PE). The secondary aim was to assess this combination in identifying pregnancies at risk for gestational hypertension and preterm birth.

Methods

This case-control study used information on maternal characteristics and residual blood samples from pregnant women who have undergone multiple marker aneuploidy screening. The median multiple of the median (MoM) of first and second trimester biochemical markers in cases (women with PE, gestational hypertension and preterm birth) and controls were compared. Biochemical markers included pregnancy-associated plasma protein A (PAPP-A), placental growth factor (PlGF), human chorionic gonadotropin (hCG), alpha feto-protein (AFP), unconjugated estriol (uE3) and Inhibin A. Logistic regression analysis was used to estimate screening performance using different marker combinations. Screening performance was defined as detection rate (DR) and false positive rate (FPR). Preterm and early-onset preeclampsia PE were defined as women with PE who delivered at < 37 and < 34 weeks of gestation, respectively.

Results

There were 147 pregnancies with PE (81 term, 49 preterm and 17 early-onset), 295 with gestational hypertension, and 166 preterm birth. Compared to controls, PE cases had significantly lower median MoM of PAPP-A (0.77 vs 1.10, p < 0.0001), PlGF (0.76 vs 1.01, p < 0.0001) and free-β hCG (0.81 vs. 0.98, p < 0.001) in the first trimester along with PAPP-A (0.82 vs 0.99, p < 0.01) and PlGF (0.75 vs 1.02, p < 0.0001) in the second trimester. The lowest first trimester PAPP-A, PlGF and free β-hCG were seen in those with preterm and early-onset PE. At a 20% FPR, 67% of preterm and 76% of early-onset PE cases can be predicted using a combination of maternal characteristics with PAPP-A and PlGF in the first trimester. The corresponding DR was 58% for gestational hypertension and 36% for preterm birth cases.

Conclusions

Maternal characteristics with first trimester PAPP-A and PlGF measured for aneuploidy screening provided reasonable accuracy in identifying women at risk of developing early onset PE, allowing triage of high-risk women for further investigation and risk-reducing therapy. This combination was less accurate in predicting women who have gestational hypertension or preterm birth.

307 Improved Compliance with Enhanced Recovery Protocol Medications for Elective Joint Replacements Using the E-Lective App

Aim

Enhanced recovery pathway(ERP) in elective joint replacements has been shown to reduce length of stay, reduce re-admission rates, and can improve early functional recovery. Local analgesia and VTE prophylaxis protocol in current use has been produced by members of the multidisciplinary team but awareness of it needs to be optimised.

Method

We performed a retrospective review of discharge summaries and prescriptions from April 1 to April 30, 2021, of all primary joint replacements at Chelsea and Westminster Hospital. These were assessed against the local ERP Protocols for elective arthroplasties. ‘E-Lective App’ - a peer to peer shared mobile application containing an offline repository of existing Enhanced Recovery medication protocols, ward directory and follow-up booking feature was presented to clinical staff at the clinical governance meeting. Prior to these, protocols were only accessed or shared through WhatsApp. Re-assessment was done a three months later for a period of one month’s July 1 to July 31, 2021.

Results

Prior to launching ‘E-Lective App,’ compliance with the ERP Discharge Medications protocol was 70.1%. At last review in July 2021 this had significantly improved to 96% on average (p&lt;0.05). Readmission rate due to pain and swelling had decreased by 65%.

Conclusions

This quality improvement project highlights the need to innovate to improve compliance to current standards of prescribing medications as part of the Enhanced Recovery Protocol. ’E-lective app’ is a novel and effective guide on maximising ERP pathway for joint replacements.

319 G-Master: A Novel 3D Printed ACL Graft Preparation System That Improves Speed and Autonomy

Aim

One of the most commonly performed procedures in orthopaedics is anterior cruciate ligament reconstruction. Autograft hamstring tendons are mostly used. The preparation of a hamstring autograft varies on patient factors and clinician choices. The use of a bulky, and expensive metal platform is usually involved, or an assistant is tasked to hold the other end of the graft. We aim to produce a 3D-printed sterilisable preparation system (G-Master) that improves autonomy and speed of the surgeon preparing the ACL graft.

Method

A stereolithography file (.stl) of the device was designed on Blender program and then manufactured on a commercial Fusion Deposition Modelling Ender 5 3-dimensional (3D) printer using a polylactic acid variant. The 3D printed parts include an attachable platform, two pillars whereby the attached pillar is where the endobutton (SN) holding the autograft sits in tension. These were autoclaved at 121°C under 15 psi of steam pressure for 30 minutes before the operation. Approval for device use was subjected to a rigorous process as class I devices as per the UK government Medicines and Healthcare Products Regulatory Agency guidelines and was then successfully used in vivo.

Results

We found the bespoke device to be beneficial in reducing graft preparation time and overall cost while increasing the autonomy of the surgeon and efficiency of the knee operating theatre list.

Conclusions

This is, to our knowledge, the first ACL graft preparation system that was produced using rapid prototyping and 3D printing. Other applications of 3D printing in manufacturing orthopaedic surgical instruments should be explored.

60 EVALUATING THE TIME THAT PATIENT’S WITH DEMENTIA/DELIRIUM SPEND IN THE EMERGENCY DEPARTMENT PRIOR TO TRANSFER TO A WARD

Background

Patients with dementia and delirium are often waiting long times in the emergency department (ED) prior to being transferred to a ward bed during an acute hospital admission. This may be associated with increased morbidity and mortality. Best practice is for rapid triage to an appropriate bed via a delirium/dementia pathway.

Our aim was to document the patient experience time (PET) for older patients with a diagnosis of dementia or delirium in ED in an urban tertiary-referral hospital.

Methods

Over a two-week period 07/12/20–21/12/20, we identified all patients admitted under a general medical specialty through ED, aged ≥65 years, with a diagnosis of dementia or delirium on the admission sheet. Patients admitted with a stroke or hip fracture were excluded. ED PET was recorded, as well as final ward destination.

Results

We included 29 patients in the study—median age was 82 years (range 71–92); 19 (66%) were female. Delirium was the presenting complaint in 79.31% (n = 23) of cases.

Sixteen (55%) patients presented between 8 am-5 pm. The average time spent from triage to ED doctor review was 1 hour 48 minutes; from ED doctor review to medical referral −1 hour 27 minutes; from medical referral to decision for medical admission—2 hours 28 minutes; from decision for medical admission to ward admission- 5 hours. Overall, the average ED PET for these patients was 10 hours 42 minutes.

Five patients (17%) were admitted directly to a Specialist Geriatric Ward (SGW). Twenty patients (69%) did not reach a SGW during the study period.

Conclusion

Patients with dementia and delirium may spend prolonged periods of time in the ED putting them at risk for multiple complications. We hope that by introduction of a dementia/delirium combined pathway and care bundle that we can reduce PET for these vulnerable patients.

61 AUDIT: MEDICATION REVIEW POST INPATIENT FALLS

Background

Falls are the most commonly reported incident in the Health Service Executive (HSE). Inappropriate medications and polypharmacy in the elderly can contribute to increased falls risk.

Our aim was to assess whether a medication review was being completed at the time of the post-fall clinician review.

Methods

We completed a retrospective chart review using an audit tool of consecutive inpatient falls, resulting in serious injury, from March–December 2019.

Standards measured against were: HSE Guideline—Service User Falls: A Practical Guide for Review, Medicines and Falls in Hospital: British Society Guidelines, STOPP & START criteria and NICE Guidelines: Falls in Older People 2013.

Results

We identified 33 charts for review (n = 33)—54.55% (18) female and 45.45% (15) male. Average age was 81 ± 11.2 years. The immediate post-fall review was mainly completed by interns (48.49% (16)) and SHO’s (39.39% (13)). A medication review was carried out 9.09% (3) of the time.

A total of n = 28 (84.85%) had poly pharmacy. When analysed for medications known to increase risk of falling, 51.52% (n = 17) were on anti-hypertensives, 45.45% (n = 15) on laxatives, 24.24% (n = 8) on sedative medications, 18.18% (n = 6) on hypnotics/anxiolytics, 15.15% (n = 5) on opioids and 15.15% (n = 5) on diuretics at the time of fall. The majority of these medications (77.42% (n = 24)) were commenced prior to admission. None of these medications were discontinued or the dose changed on review post fall.

Conclusion

Our audit demonstrates that in a cohort of patients who had an inpatient fall medication discontinuation and dose reductions were not performed. Yet, a high burden of polypharmacy and high-risk falls medication were found. This may result in missing a pertinent opportunity to prevent future falls. We advise a structured medication review is carried out for each patient who suffers an in-patient fall to efficiently modify such an easily identifiable risk factor.

Thirty-day mortality following surgical management of hip fractures during the COVID-19 pandemic: findings from a prospective multi-centre UK study

PURPOSE

Thirty-day mortality of patients with hip fracture is well researched and predictive; validated scoring tools have been developed (Nottingham Hip Fracture Score, NHFS). COVID-19 has significantly greater mortality in the elderly and comorbid patients which includes hip fracture patients. Non-operative treatment is not appropriate due to significantly higher mortality, and therefore, these patients are often exposed to COVID-19 in the peri-operative period. What is unclear is the effect of concomitant COVID-19 infection in these patients.

METHODS

A multicentre prospective study across ten sites in the United Kingdom (responsible for 7% of hip fracture patients per annum in the UK). Demographic and background information were collected by independent chart review. Data on surgical factors included American Society of Anesthesiologists (ASA) score, time to theatre, Nottingham Hip fracture score (NHFS) and classification of fracture were also collected between 1st March 2020 and 30th April 2020 with a matched cohort from the same period in 2019.

RESULTS

Actual and expected 30-day mortality was found to be significantly higher than expected for 2020 COVID-19 positive patients (RR 3.00 95% CI 1.57-5.75, p < 0.001), with 30 observed deaths compared against the 10 expected from NHFS risk stratification.

CONCLUSION

COVID-19 infection appears to be an independent risk factor for increased mortality in hip fracture patients. Whilst non-operative management of these fractures is not suggested due to the documented increased risks and mortality, this study provides evidence to the emerging literature of the severity of COVID-19 infection in surgical patients and the potential impact of COVID-19 on elective surgical patients in the peri-operative period.

Prenatal screening for trisomy 21: a comparative performance and cost analysis of different screening strategies

Background

Prenatal screening for chromosome aneuploidies have constantly been evolving, especially with the introduction of cell-free fetal DNA (cfDNA) screening in the most recent years. This study compares the performance, costs and timing of test results of three cfDNA screening implementation strategies: contingent, reflex and primary.

Methods

We modelled enhanced first trimester screening (eFTS) as the first-tier test in contingent or reflex strategies. cfDNA test was performed contingent on or reflex from eFTS results. A comparison was made between cfDNA screening using sequencing technology and Rolling Circle Amplification (RCA)/imaging solution. All model assumptions were based on results from previous publications or information from the Ontario prenatal screening population.

Results

At an eFTS risk cut-off of ≥1/1000, contingent and reflex cfDNA screening have the same detection rate (DR) (94%) for trisomy 21. Reflex cfDNA screening using RCA/Imaging solution provided the lowest false positive rate and cost. The number of women requiring genetic counselling and diagnostic testing was significantly reduced and women received their cfDNA screening result 9 days sooner compared with the contingent model. While primary cfDNA screening improved the trisomy 21 DR by 3–5%, it was more costly and more women required diagnostic testing.

Conclusion

Reflex cfDNA screening is the most cost-effective prenatal screening strategy. It can improve the efficiency of prenatal aneuploidy screening by reducing the number of patient visits and providing more timely results.

The validity of two widely used commercial and research-grade activity monitors, during resting, household and activity behaviours

Wearable devices are increasingly prevalent in research environments for the estimation of energy expenditure (EE) and heart rate (HR). The aim of this study was to validate the HR and EE estimates of the Fitbit charge 2 (FC2), and the EE estimates of the Sensewear armband mini (SWA). We recruited 59 healthy adults to participate in walking, running, cycling, sedentary and household tasks. Estimates of HR from the FC2 were compared to a HR chest strap (Polar) and EE to a stationary metabolic cart (Vyntus CPX). The SWA overestimated overall EE by 0.03 kcal/min−1 and was statistically equivalent to the criterion measure, with a mean absolute percentage error (MAPE) of 29%. In contrast, the FC2 was not equivalent overall (MAPE = 44%). In household tasks, MAPE values of 93% and 83% were observed for the FC2 and SWA, respectively. The FC2 HR estimates were equivalent to the criterion measure overall. The SWA is more accurate than the commercial-grade FC2. Neither device is consistently accurate across the range of activities used in this study. The HR data obtained from the FC2 is more accurate than its EE estimates and future research may focus more on this variable.

Organ and Tissue Donation in Irish Paediatric Intensive Care

Aim Our aim was to present an overview of patterns of paediatric organ donation in the Republic of Ireland from January 2007 to January 2018. Methods We performed a retrospective audit of organ donation practice in paediatric intensive care units (PICU) in Ireland. Results Thirty-six children donated organs or tissue heart valves over the 11-year period. There were 13 paediatric organ donors between 2007 and 2012, this increased to 23 paediatric organ donors between 2013 and 2017. 2017 had the highest number of organ donors at 9 Conclusion Organ donation in Irish PICUs has increased over the last 11 years due to a combination of factors: improved resourcing and organization of Organ Donation Transplantation Ireland (ODTI), the establishment of clinical leads (both medical and nursing) in organ donation, a heightened awareness of organ donation and improved specialist Intensive Care dedicated consultant staffing. Finally organ donation is possible only through the generosity and altruism of bereaved families. Outcomes from donated organs have been excellent throughout the 11 year period audited.

Changes in food reward during weight management interventions - a systematic review

BACKGROUND

Does food reward increase or decrease during weight management attempts? Excessive food intake is the main behavioural determinant of obesity; therefore, a better understanding of food reward and its relationship with food intake and weight outcomes could contribute to more effective weight management solutions.

METHODS

This systematic review assessed the role of changes in food reward (directly or indirectly measured) during weight management interventions. Four databases were searched for articles published until April 2018 involving weight management interventions (all types and designs) in healthy adults with overweight or obesity.

RESULTS

Of 239 full-text articles assessed, 17 longitudinal studies were included. Twelve studies reported a significant change in food reward over time. When compared with control interventions, dietary, pharmacological, behavioural and cognitive interventions were effective in decreasing liking and/or wanting for high-energy food using a range of methodologies to assess food reward. Three studies reported that decreased food reward was associated with improved weight management outcomes.

CONCLUSION

Food reward appears to decrease rather than increase during weight management interventions. Future studies specifically targeting the hedonic aspects of food intake (liking/wanting) are needed to gain a better understanding of how to uncouple the obesogenic relationship between food reward and overeating.

Surgical management of a giant hepatic cyst with suspicious radiological features

Cysts in the liver have a wide variety of aetiologies. Important features of malignancy based on various imaging techniques must be considered prior to any intervention. Perioperative decision making in complex or difficult cysts is key to appropriate patient management. A 66-year-old woman was referred to the outpatient department with a one-year history of intermittent, sharp, right upper quadrant pain, radiating to her back. Computed tomography and magnetic resonance imaging showed a large cyst in the right and left lobes of the liver with portal inflow closely related. Features such as wall thickening suspicious for cystadenocarcinoma were present. An open resection was planned but, based on perioperative findings, the cyst had features making it unsafe to perform excision. De-roofing, carefully controlled drainage and assessment of the internal aspect of the cyst were performed, which revealed an extremely close relationship to portal inflow. This case describes the decision-making process when faced with complex indeterminate pathology of the liver and proximity of critical structures.

Long-term efficacy of novel therapies in moderate-to-severe plaque psoriasis: a systematic review and network meta-analysis of PASI response

Background

Patients with moderate‐to‐severe psoriasis require long‐term treatment, yet few trials compare outcomes beyond a short‐term induction period. Quantitative comparisons of long‐term outcomes in patients with psoriasis are limited. To our knowledge, no network meta‐analysis (NMA) of such data has been performed.

Objective

To compare novel systemic therapies, both biologic and non‐biologic, approved for moderate‐to‐severe psoriasis by conducting a systematic review (SR) and NMA of Psoriasis Area and Severity Index (PASI) outcomes measured at or around 1 year.

Methods

An SR was conducted to identify studies reporting PASI 75, PASI 90 and PASI 100 responses. Feasibility of an NMA on maintenance phase endpoints was assessed and sources of heterogeneity considered. Data appropriate for analysis were modelled using a Bayesian multinomial likelihood model with probit link. Wherever possible, data corresponding to an intention‐to‐treat approach with non‐responder imputation were used.

Results

Twenty‐four studies reporting outcomes at 40–64 weeks were identified, but heterogeneity in study design allowed synthesis of only 17. Four 52‐week randomized controlled trials (RCTs) comprised the primary analysis, which found brodalumab was significantly more efficacious than secukinumab, ustekinumab and etanercept. Secukinumab was also more efficacious than ustekinumab and both outperformed etanercept. In a secondary analysis, evidence from 13 additional studies and 4 further therapies (adalimumab, apremilast, infliximab and ixekizumab) was included by comparing long‐term outcomes from active interventions to placebo outcomes extrapolated from induction. Results were consistent with the primary analysis: brodalumab was most effective, followed by ixekizumab and secukinumab, then ustekinumab, infliximab and adalimumab. Etanercept and apremilast had the lowest expected long‐term efficacy. Results were similar when studies with low prior exposure to biological therapies were excluded.

Conclusion

Results suggest that brodalumab is associated with a higher likelihood of sustained PASI response, including complete clearance, at week 52 than comparators. Further long‐term active‐comparator RCT data are required to better assess relative efficacy across therapies.

Results from the third Scottish National Prevalence Survey: is a population health approach now needed to prevent healthcare-associated infections?

BACKGROUND

Healthcare-associated infections (HCAIs) are a major public health concern and a significant cause of morbidity and mortality. A robust and current evidence base that is specific to local, national and Europe-wide settings is necessary to inform the development of strategies to reduce HCAI and contain antimicrobial resistance.

AIM

To measure the prevalence of HCAI and antimicrobial prescribing and identify key priority areas for interventions to reduce the burden of infection.

METHODS

A national rolling point-prevalence survey (PPS) in National Health Service (NHS) acute, NHS non-acute, NHS paediatric, and independent hospitals was carried out between September and November 2016 using the European Centre for Disease Prevention and Control protocol designed for the European PPS.

FINDINGS

The prevalence of HCAI was 4.6%, 2.7%, and 3.2% in acute adults, paediatric and non-acute patient groups, respectively. The most frequent HCAI types reported in adult patients were urinary tract infection and pneumonia. The prevalence of antimicrobial prescribing was 35.7%, 29.3%, and 13.8% in acute adults, paediatric, and non-acute patient groups, respectively. Respiratory, skin and soft tissue, gastrointestinal, and urinary tract infections were the most common infections being treated at the time of survey.

CONCLUSION

HCAI continues to be a public health concern in Scotland. Urinary tract infection and pneumonia continue to place a significant burden on patients and on healthcare delivery, including those that develop in the community and require hospital admission. A broader population health approach which focuses on reducing the risk of infection upstream would reduce these infections in both community and hospital settings.

Abstract P5-19-02: Withdrawn

This abstract was withdrawn by the authors.

Efficacy and safety of rivaroxaban thromboprophylaxis after arthroplasty of the hip or knee: retrospective cohort study

Introduction Venous thromboembolism (VTE) is a potentially fatal complication of hip arthroplasty and knee arthroplasty. The National Institute for Health and Care Excellence recommend rivaroxaban for VTE prevention. Amid concerns over bleeding complications, the modified thromboprophylaxis policy of Chelsea and Westminster Hospital (CWH; London, UK) advises enoxaparin given after surgery in the inpatient setting followed by rivaroxaban upon hospital discharge. This retrospective study investigated the efficacy and safety of rivaroxaban in this novel, modified venous-prophylaxis regimen in a surgical orthopaedic cohort at CWH. Methods A total of 479 patients who received modified thromboprophylaxis treatment at CWH after hip arthroplasty or knee arthroplasty between April 2013 and October 2014 formed the study cohort. Seven outcomes based on efficacy and safety while undergoing treatment with rivaroxaban were investigated: symptomatic deep-vein thrombosis (DVT), pulmonary embolism (PE), death, stroke, myocardial infarction (MI), major bleeding episodes (MBEs) and non-major bleeding episodes (NMBEs). Median follow-up was 369 days. Fisher's exact and Mann-Whitney U-tests were adopted to identify associations with these outcomes. Results Prevalence of symptomatic PE, DVT, death, stroke and MI during treatment was zero. One (0.2%) MBE and nine (1.9%) NMBEs occurred. The MBE (a wound haematoma) required a return to theatre for aspiration. Off-treatment VTEs occurred in four (0.8%) patients after completion of a course of rivaroxaban, and were associated with known risk factors. Conclusions Rivaroxaban is an effective and safe anticoagulant for thromboprophylaxis after hip arthroplasty or knee arthroplasty if used in a modified regimen involving enoxaparin administered in the inpatient setting followed by rivaroxaban upon hospital discharge.

Effect of Deutetrabenazine on Chorea Among Patients With Huntington Disease: A Randomized Clinical Trial

IMPORTANCE

Deutetrabenazine is a novel molecule containing deuterium, which attenuates CYP2D6 metabolism and increases active metabolite half-lives and may therefore lead to stable systemic exposure while preserving key pharmacological activity.

OBJECTIVE

To evaluate efficacy and safety of deutetrabenazine treatment to control chorea associated with Huntington disease.

DESIGN, SETTING, AND PARTICIPANTS

Ninety ambulatory adults diagnosed with manifest Huntington disease and a baseline total maximal chorea score of 8 or higher (range, 0-28; lower score indicates less chorea) were enrolled from August 2013 to August 2014 and randomized to receive deutetrabenazine (n = 45) or placebo (n = 45) in a double-blind fashion at 34 Huntington Study Group sites.

INTERVENTIONS

Deutetrabenazine or placebo was titrated to optimal dose level over 8 weeks and maintained for 4 weeks, followed by a 1-week washout.

MAIN OUTCOMES AND MEASURES

Primary end point was the total maximal chorea score change from baseline (the average of values from the screening and day-0 visits) to maintenance therapy (the average of values from the week 9 and 12 visits) obtained by in-person visits. This study was designed to detect a 2.7-unit treatment difference in scores. The secondary end points, assessed hierarchically, were the proportion of patients who achieved treatment success on the Patient Global Impression of Change (PGIC) and on the Clinical Global Impression of Change (CGIC), the change in 36-Item Short Form- physical functioning subscale score (SF-36), and the change in the Berg Balance Test.

RESULTS

Ninety patients with Huntington disease (mean age, 53.7 years; 40 women [44.4%]) were enrolled. In the deutetrabenazine group, the mean total maximal chorea scores improved from 12.1 (95% CI, 11.2-12.9) to 7.7 (95% CI, 6.5-8.9), whereas in the placebo group, scores improved from 13.2 (95% CI, 12.2-14.3) to 11.3 (95% CI, 10.0-12.5); the mean between-group difference was -2.5 units (95% CI, -3.7 to -1.3) (P < .001). Treatment success, as measured by the PGIC, occurred in 23 patients (51%) in the deutetrabenazine group vs 9 (20%) in the placebo group (P = .002). As measured by the CGIC, treatment success occurred in 19 patients (42%) in the deutetrabenazine group vs 6 (13%) in the placebo group (P = .002). In the deutetrabenazine group, the mean SF-36 physical functioning subscale scores decreased from 47.5 (95% CI, 44.3-50.8) to 47.4 (44.3-50.5), whereas in the placebo group, scores decreased from 43.2 (95% CI, 40.2-46.3) to 39.9 (95% CI, 36.2-43.6), for a treatment benefit of 4.3 (95% CI, 0.4 to 8.3) (P = .03). There was no difference between groups (mean difference of 1.0 unit; 95% CI, -0.3 to 2.3; P = .14), for improvement in the Berg Balance Test, which improved by 2.2 units (95% CI, 1.3-3.1) in the deutetrabenazine group and by 1.3 units (95% CI, 0.4-2.2) in the placebo group. Adverse event rates were similar for deutetrabenazine and placebo, including depression, anxiety, and akathisia.

CONCLUSIONS AND RELEVANCE

Among patients with chorea associated with Huntington disease, the use of deutetrabenazine compared with placebo resulted in improved motor signs at 12 weeks. Further research is needed to assess the clinical importance of the effect size and to determine longer-term efficacy and safety.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT01795859.

Sickle cell disease: time for a targeted neonatal screening programme

Ireland has seen a steady increase in paediatric sickle cell disease (SCD). In 2005, only 25% of children with SCD were referred to the haemoglobinopathy service in their first year. A non-funded screening programme was implemented. This review aimed to assess the impact screening has had. All children referred to the haemoglobinopathy service born in Ireland after 2005 were identified. Data was collected from the medical chart and laboratory system. Information was analysed using Microsoft Excel. 77 children with SCD were identified. The median age at antibiotic commencement in the screened group was 56 days compared with 447 days in the unscreened group, p = < 0.0003. 22 (28%) of infants were born in centre's that do not screen and 17 (81%) were over 6 months old at referral, compared with 14 (21%) in the screened group. 6 (27%) of those in the unscreened group presented in acute crisis compared with 2 (3%) in the screened population. The point prevalence of SCD in Ireland is 0.2% in children under 15 yr of African and Asian descent. We identified delays in referral and treatment, which reflect the lack of government funded support and policy. We suggest all maternity units commence screening for newborns at risk of SCD. It is a cost effective intervention with a number needed to screen of just 4 to prevent a potentially fatal crisis.

Appetite control and energy balance: impact of exercise

Exercise is widely regarded as one of the most valuable components of behaviour that can influence body weight and therefore help in the prevention and management of obesity. Indeed, long-term controlled trials show a clear dose-related effect of exercise on body weight. However, there is a suspicion, particularly fuelled by media reports, that exercise serves to increase hunger and drive up food intake thereby nullifying the energy expended through activity. Not everyone performing regular exercise will lose weight and several investigations have demonstrated a huge individual variability in the response to exercise regimes. What accounts for this heterogeneous response? First, exercise (or physical activity) through the expenditure of energy will influence the energy balance equation with the potential to generate an energy deficit. However, energy expenditure also influences the control of appetite (i.e. the physiological and psychological regulatory processes underpinning feeding) and energy intake. This dynamic interaction means that the prediction of a resultant shift in energy balance, and therefore weight change, will be complicated. In changing energy intake, exercise will impact on the biological mechanisms controlling appetite. It is becoming recognized that the major influences on the expression of appetite arise from fat-free mass and fat mass, resting metabolic rate, gastric adjustment to ingested food, changes in episodic peptides including insulin, ghrelin, cholecystokinin, glucagon-like peptide-1 and tyrosine-tyrosine, as well as tonic peptides such as leptin. Moreover, there is evidence that exercise will influence all of these components that, in turn, will influence the drive to eat through the modulation of hunger (a conscious sensation reflecting a mental urge to eat) and adjustments in postprandial satiety via an interaction with food composition. The specific actions of exercise on each physiological component will vary in strength from person to person (according to individual physiological characteristics) and with the intensity and duration of exercise. Therefore, individual responses to exercise will be highly variable and difficult to predict.

Diabetic retinopathy equity profile in a multi-ethnic, deprived population in Northern England

PURPOSE

Equity profiles are an established public health tool used to systematically identify and address inequity within health and health services. Our aim was to conduct an equity profile to identify inequity in eye health across Leeds and Bradford. This paper presents results of findings for diabetic retinopathy in Bradford and Airedale.

METHODS

A variety of routine health data were included and sub-analysed by measures of equity, including age, sex, ethnicity, and deprivation to identify inequity in eye health and healthcare. The Spearman Rank Correlation Coefficient was used to determine the association between variables.

RESULTS

The prevalence of diagnosed diabetes in Bradford and Airedale district is 6.6% compared to 4.3% in nearby Leeds and 5.1% nationally. The age-standardised prevalence of diagnosed diabetic retinopathy within Bradford and Airedale is 2.21% (95% CI 1.54-2.26%), with a disproportionately high prevalence of disease in the Pakistani population and the most deprived parts of the population. There was a poorer uptake of diabetic retinopathy screening in more deprived parts of the district and the proportions with a higher rate of referral to ophthalmology following the screening in Black and Minority Ethnic populations compared with the white population (13.2% vs 6.9%). Uptake of secondary care outpatient appointments is much lower in more deprived populations.

CONCLUSION

Inequalities are inherent in diabetic retinopathy prevalence, diagnosis, and treatment. The reasons for these inequities are multi-factorial and further investigation of reasons for poor uptake of services is required. Addressing the inequalities in eye health and healthcare requires cross-organisational collaboration.