Obesity does not impact complications and conversion to total knee arthroplasty after high tibial osteotomy: A systematic review

PURPOSE

The purpose of this systematic review is to consolidate outcomes of obese patients undergoing high tibial osteotomy and to investigate the effect of obesity on postoperative outcomes, including symptomatic relief and time to conversion to arthroplasty.

METHODS

Medline, Embase and Cochrane Library were searched from database inception up to April 2023 according to PRISMA guidelines by two reviewers. Search terms including 'obesity', 'BMI', 'osteotomy' and 'high tibial osteotomy (HTO)' were included to identify all relevant articles. Only studies that explicitly reported outcomes for obese patients were included. Disagreements in study inclusion or quality assessment were resolved by a senior third reviewer. Metrics compared include time to arthroplasty, preoperative and postoperative mechanical tibiofemoral angle (mTFA), patient-reported satisfaction scores and postoperative complications.

RESULTS

Nine studies comparing 973 patients were included. The mean age was 52.7 ± 4.2 years old and 38.4% were male. Six studies performed the medial opening-wedge HTO, and three utilized the medial wedge closing technique. Most studies indicated significant improvement following surgical intervention with satisfactory outcomes in obese and nonobese patients. In addition, differences in complication rates were minimal between obese and nonobese patients (n.s.), while functional scores did not vary significantly. Conversion to total knee arthroplasty was not found to increase in obese patients (n.s.).

CONCLUSION

Obesity does not appear to carry a greater complication risk or worse outcomes following high tibial osteotomies, and surgeons should consider HTO a viable option for young obese patients with symptomatic unicompartmental chondral wear with coronal limb malalignment.

LEVEL OF EVIDENCE

Level IV.

High Research Productivity During Orthopaedic Surgery Residency May Be Predicted by Number of Publications as a Medical Student

Introduction

Orthopaedic applicants have increased the average number of publications on their residency application to compete with the growing competitiveness of the field. The purpose of this study was to assess whether research productivity before orthopaedic residency and caliber of one's institution is correlated with academic productivity during residency.

Methods

Scopus was used to extract publication metrics. Quantity and quality (how often the publications were cited) were analyzed at 2 different time periods: before and during residency. All subjects in the study had graduated an ACGME-accredited orthopaedic surgery residency in 2021. Military residents, international medical graduates, and residents not listed on their department's website were excluded. Residents were categorized as both high (≥2 publications) or low (<2 publications) publishers according to their pre-residency publications. They were also categorized based on their program's Jones et al. research productivity ranking.

Results

For the 758 residents, the median number of publications was 0 (Interquartile Range [IQR]: 0-2) and 3 (IQR: 1-6) before and during residency, respectively. High publishing medical students had more publications during training than low publishers (6 [IQR: 3-14] and 2 [IQR: 1-4], p < 0.001). Residents at higher ranked programs also had more publications (4 [IQR: 2-9] and 2 [IQR: 0-4], p < 0.001). High publishing students now training at lower ranked institutions had more publications during residency than low publishers who trained at more productive institutions (4 [IQR: 1-9] and 3 [IQR: 1-6], p < 0.001).

Conclusion

Having 2 or more publications before residency is correlated with an increased number of publications during residency. While attending a higher academically productive program is associated with increased resident publications, a high publishing medical student would be expected to have more publications during residency than a low publishing student, regardless of program rank. Notably, most matched applicants continue to have zero publications before matriculation.

Analysis of primary care electronic health record data of people living with hepatitis B virus: infection and hepatocellular carcinoma risk associated with socio-economic deprivation

OBJECTIVES

We set out to characterise chronic hepatitis B (CHB) in the primary care population in England and investigate risk factors for progression to hepatocellular carcinoma (HCC).

STUDY DESIGN

Retrospective cohort study.

METHODS

We identified 8039 individuals with CHB in individuals aged ≥18 years between 1999 and 2019 in the English primary care database QResearch. HCC risk factors were investigated using Cox proportional hazards modelling.

RESULTS

Most of those with a record of CHB were males (60%) of non-White ethnicity (>70%), and a high proportion were in the most deprived Townsend deprivation quintile (44%). Among 7029 individuals with longitudinal data, 161 HCC cases occurred. Increased HCC hazards were significantly associated with male sex (adjusted hazards ratio [aHR] 3.17, 95% confidence interval [95% CI] 1.92-5.23), in the fifth deprivation quintile as compared to the third quintile (aHR 1.69, 95% CI 1.01-2.84), with older age (for age groups 56-65 and ≥66 years, compared to 26-35 years, aHRs 2.82 [95% CI 1.45-5.46] and 3.76 [95% CI 1.79-7.9], respectively), Caribbean ethnicity (aHR 3.32, 95% CI 1.43-7.71, compared to White ethnicity), ascites (aHR 3.15, 95% CI 1.30-7.67), cirrhosis (aHR 6.55, 95% CI 4.57-9.38) and peptic ulcer disease (aHR 2.26, 95% CI 1.45-3.51).

CONCLUSIONS

Targeting interventions and HCC surveillance at vulnerable groups is essential to improve CHB outcomes and to support progress towards international goals for the elimination of hepatitis infection as a public health threat.

Anterior Cruciate Ligament Reconstruction With Quadriceps Tendon Autograft: Surgical Technique Using Augmentation With a Biocomposite Scaffold

Anterior cruciate ligament (ACL) reconstruction augmentation continues to be widely studied. Both biologic and synthetic augments have been employed to enhance ACL healing and provide early protection. The BioBrace is a biocomposite scaffold that both mechanically reinforces the graft while biologically enhancing graft healing. The purpose of this article is to describe augmentation of an ACL reconstruction with BioBrace.

Whole-genome sequencing to investigate transmission of SARS-CoV-2 in the acute healthcare setting: a systematic review

BACKGROUND

Whole-genome sequencing (WGS) has been used widely to elucidate transmission of SARS-CoV-2 in acute healthcare settings, and to guide infection, prevention, and control (IPC) responses.

AIM

To systematically appraise available literature, published between January 1st, 2020 and June 30th, 2022, describing the implementation of WGS in acute healthcare settings to characterize nosocomial SARS-CoV-2 transmission.

METHODS

Searches of the PubMed, Embase, Ovid MEDLINE, EBSCO MEDLINE, and Cochrane Library databases identified studies in English reporting the use of WGS to investigate SARS-CoV-2 transmission in acute healthcare environments. Publications involved data collected up to December 31st, 2021, and findings were reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement.

FINDINGS

In all, 3088 non-duplicate records were retrieved; 97 met inclusion criteria, involving 62 outbreak analyses and 35 genomic surveillance studies. No publications from low-income countries were identified. In 87/97 (90%), WGS supported hypotheses for nosocomial transmission, while in 46 out of 97 (47%) suspected transmission events were excluded. An IPC intervention was attributed to the use of WGS in 18 out of 97 (18%); however, only three (3%) studies reported turnaround times ≤7 days facilitating near real-time IPC action, and none reported an impact on the incidence of nosocomial COVID-19 attributable to WGS.

CONCLUSION

WGS can elucidate transmission of SARS-CoV-2 in acute healthcare settings to enhance epidemiological investigations. However, evidence was not identified to support sequencing as an intervention to reduce the incidence of SARS-CoV-2 in hospital or to alter the trajectory of active outbreaks.

"Oh! How Modern! And... Are You Ok with That?": Consensually Non-Monogamous People's Experiences When Accessing Sexual Health Care

The current research explored consensually non-monogamous peoples' experiences accessing sexual healthcare. Using a mixed method approach, a sample of 67 consensually non-monogamous individuals (48% Polyamorous; 42% Relationship Anarchy/Solo polyamory; 6% Swingers; 4% Uncategorized) reported having significantly lower rates of trust in healthcare professionals compared to standardized scores. Sixty-three percent of participants reported disclosing their relationship status to a clinician when accessing sexual health services, whereas 37% sometimes or never disclosed. Qualitative responses identified that some participants reported a willingness to be open about their relationships, but many chose to "pass" as monogamous to both simplify and streamline their interactions as well as to avoid potential stigma. Participants reported a wide range of experiences with clinicians from those who were accepting and professional, to some who displayed prejudice and withheld treatment. This research outlines some of the experiences and challenges presented to consensual non-monogamists when accessing sexual healthcare as well as providing suggestions for clinicians to help remove some of the barriers to appropriate patient care.

Rates of Complications and Readmissions: In-Patient vs Outpatient ORIF of Calcaneus Fractures

Category:

Hindfoot; Trauma

Introduction/Purpose:

Calcaneus fractures are common injuries to the hindfoot. The safety of in-patient versus outpatient treatment in patients with calcaneus fractures remains unclear. The aim of the present study was to assess differences in wound complications and readmissions in operative calcaneus fractures treated with open reduction and internal fixation (ORIF) in an in- patient versus outpatient setting.

Methods:

Patients undergoing ORIF for calcaneus fractures from 2012 to 2020 were reviewed. Inclusion criteria were age greater than 18 years and an operative calcaneus fracture treated with the sinus tarsi approach (STA). Exclusion criteria consisted of a minimum of three months follow-up, open calcaneal fractures or fracture dislocations, inpatients with polytrauma, and patients without a preoperative computed tomography (CT) scan. A total of 113 patients met inclusion criteria with 24 (21%) managed inpatient and 89 (79%) managed as outpatient. The primary outcomes were deep infection defined as return to the operating room for debridement with positive cultures and readmissions. Secondary outcomes included implant related pain and unplanned return to the operating room.

Results:

Inpatients had a higher percentage of ASA classification 3&4 patients (58.3% vs 29.2%, p=0.008). Outpatients had a longer delay in days between injury and definitive fixation (mean 8 (8.9 SD, 0-31 range) vs. 14 (12.4 SD, 0-91 range) days, p=0.009). There were no statistically significant differences in the incidence of deep infections (8.3% vs. 4.5%, p=.606), implant related pain (8.3% vs. 15.7%, p=.516), return to the operating room (16.7% vs. 15.7%, p=1.0) or readmissions (4.2% vs. 3.4%, p=1.0) between inpatient and outpatient groups including in binary logistic regression models (p>.3 for all). In our retrospective study of patients undergoing operative repair of isolated calcaneus fractures with STA, there was no increased risk of wound complications or readmissions when calcaneus fractures were treated in an outpatient setting.

Conclusion:

In our retrospective study of patients undergoing operative repair of isolated calcaneus fractures with STA, there was no increased risk of wound complications or readmissions when calcaneus fractures were treated in an outpatient setting.

Overall survival in the OlympiA phase III trial of adjuvant olaparib in patients with germline pathogenic variants in BRCA1/2 and high risk, early breast cancer

BACKGROUND

The randomized, double-blind OlympiA trial compared 1 year of the oral poly(adenosine diphosphate-ribose) polymerase inhibitor, olaparib, to matching placebo as adjuvant therapy for patients with pathogenic or likely pathogenic variants in germline BRCA1 or BRCA2 (gBRCA1/2pv) and high-risk, human epidermal growth factor receptor 2-negative, early breast cancer (EBC). The first pre-specified interim analysis (IA) previously demonstrated statistically significant improvement in invasive disease-free survival (IDFS) and distant disease-free survival (DDFS). The olaparib group had fewer deaths than the placebo group, but the difference did not reach statistical significance for overall survival (OS). We now report the pre-specified second IA of OS with updates of IDFS, DDFS, and safety.

PATIENTS AND METHODS

One thousand eight hundred and thirty-six patients were randomly assigned to olaparib or placebo following (neo)adjuvant chemotherapy, surgery, and radiation therapy if indicated. Endocrine therapy was given concurrently with study medication for hormone receptor-positive cancers. Statistical significance for OS at this IA required P < 0.015.

RESULTS

With a median follow-up of 3.5 years, the second IA of OS demonstrated significant improvement in the olaparib group relative to the placebo group [hazard ratio 0.68; 98.5% confidence interval (CI) 0.47-0.97; P = 0.009]. Four-year OS was 89.8% in the olaparib group and 86.4% in the placebo group (Δ 3.4%, 95% CI -0.1% to 6.8%). Four-year IDFS for the olaparib group versus placebo group was 82.7% versus 75.4% (Δ 7.3%, 95% CI 3.0% to 11.5%) and 4-year DDFS was 86.5% versus 79.1% (Δ 7.4%, 95% CI 3.6% to 11.3%), respectively. Subset analyses for OS, IDFS, and DDFS demonstrated benefit across major subgroups. No new safety signals were identified including no new cases of acute myeloid leukemia or myelodysplastic syndrome.

CONCLUSION

With 3.5 years of median follow-up, OlympiA demonstrates statistically significant improvement in OS with adjuvant olaparib compared with placebo for gBRCA1/2pv-associated EBC and maintained improvements in the previously reported, statistically significant endpoints of IDFS and DDFS with no new safety signals.

A Prospective Randomized Controlled Trial of Methylprednisolone for Postoperative Pain Management of Surgically Treated Distal Radius Fractures

PURPOSE

Perioperative glucocorticoids have been effectively used as a pain management regimen for reducing pain after hand surgery. We hypothesize that a methylprednisolone taper (MPT) course following surgery will reduce pain and opioid consumption in the early postoperative period.

METHODS

This study was a randomized controlled trial of patients undergoing surgical fixation for distal radius fracture. Before surgery, patients were randomly assigned to receive preoperative dexamethasone only or preoperative dexamethasone followed by a 6-day oral MPT. Patient pain and opioid consumption data were collected for 7 days after surgery using a patient-reported pain journal.

RESULTS

Our study consisted of 56 patients enrolled from November 2018 to March 2020. Twenty-eight patients each were assigned to the control and treatment groups. Demographic characteristics such as age, body mass index, the dominant side affected, smoking status, diabetes status, and current narcotic use were similar between the control and treatment groups. With a noticeable, significant reduction starting on postoperative day 2, patients who received an MPT course consumed substantially less opioids during the first 7 days (7.8 ± 7.2 pills compared with 15.5 ± 11.5 pills, a 50% reduction). These patients also consumed significantly fewer oral morphine equivalents than the control group (81.2 vs 41.2). A significant difference in the pain visual analog scale scores between the 2 groups was noted starting on postoperative day 2, with 48% of the treatment group reporting no pain by postoperative day 6. No adverse events, including infection or complications of wound or bone healing, were seen in either group.

CONCLUSIONS

There was an early improvement in pain and reduction in early opioid consumption with a 6-day MPT following surgical fixation for distal radius fracture. With no increased risk of adverse events in our sample, MPT may be a safe and effective way to reduce postoperative pain.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic II.

Cervical cancer screening utilization, and associated factors, in Nepal: a systematic review and meta-analysis

OBJECTIVE

To systematically appraise the existing published literature on cervical cancer screening utilization, and associated barriers and facilitators, in Nepal.

STUDY DESIGN

Systematic literature review and meta-analysis.

METHODS

PubMed/MEDLINE, CINAHL, Scopus, Embase, and, Google Scholar were systematically searched using Preferred Reporting Items for Systematic Review and Meta-Analysis guideline. All quantitative and qualitative studies reporting cervical cancer screening (using the Pap smear test or visual inspection with acetic acid or human papillomavirus test) utilization, barriers, and facilitators for screening were identified. A meta-analysis was performed to estimate Nepal's pooled cervical cancer screening utilization proportion.

RESULTS

The search yielded 97 records, of which 17 studies were included. Fifteen studies were quantitative and two were qualitative. Of the 17 studies, six were hospital-based and six were community-based. The pooled cervical cancer screening utilization proportion (using Pap smear test) among Nepalese women was 17% from the studies in the hospital settings, and 16% in the community. Six studies reported barriers to cervical cancer screening, of which four reported embarrassments related to the gynecological examination and a low level of knowledge on cervical cancer. Three (of four) studies reported health personnel, and two studies reported screening services-related facilitators for cervical cancer screening.

CONCLUSION

Our review reported that cervical cancer screening utilization (16%) is more than four times lower than the national target (70%) in Nepal. Multiple barriers such as low levels of knowledge and embarrassment are associated with cervical cancer screening utilization. Health personnel's gender, counseling, and privacy of screening services were commonly reported facilitators. These findings could help to inform future research, and policy efforts to increase cervical cancer screening utilization in Nepal.

Severity of oEsophageal Anastomotic Leak in patients after oesophagectomy: the SEAL score

Background

Anastomotic leak (AL) is a common but severe complication after oesophagectomy. It is unknown how to determine the severity of AL objectively at diagnosis. Determining leak severity may guide treatment decisions and improve future research. This study aimed to identify leak-related prognostic factors for mortality, and to develop a Severity of oEsophageal Anastomotic Leak (SEAL) score.

Methods

This international, retrospective cohort study in 71 centres worldwide included patients with AL after oesophagectomy between 2011 and 2019. The primary endpoint was 90-day mortality. Leak-related prognostic factors were identified after adjusting for confounders and were included in multivariable logistic regression to develop the SEAL score. Four classes of leak severity (mild, moderate, severe, and critical) were defined based on the risk of 90-day mortality, and the score was validated internally.

Results

Some 1509 patients with AL were included and the 90-day mortality rate was 11.7 per cent. Twelve leak-related prognostic factors were included in the SEAL score. The score showed good calibration and discrimination (c-index 0.77, 95 per cent c.i. 0.73 to 0.81). Higher classes of leak severity graded by the SEAL score were associated with a significant increase in duration of ICU stay, healing time, Comprehensive Complication Index score, and Esophagectomy Complications Consensus Group classification.

Conclusion

The SEAL score grades leak severity into four classes by combining 12 leak-related predictors and can be used to the assess severity of AL after oesophagectomy.

Guillain-Barré Syndrome and Unilateral Optic Neuritis Following Vaccination for COVID-19: A Case Report and Literature Review

A 71-year-old woman presented 2 weeks after vaccination with the first dose of Vaxzevria (AstraZeneca, Oxford) for COVID-19 with a left lower motor neuron facial nerve palsy, which progressed to bilateral involvement. This was accompanied by bilateral proximal leg weakness. She was diagnosed with the 'facial diplegia with paraesthesia' variant of Guillain-Barré syndrome. Seven weeks post vaccination she developed painless loss of vision in the right eye. The visual acuity in that eye was light perception only with a right relative afferent pupillary defect and right optic disc swelling. A diagnosis of optic neuritis was made and she received pulsed intravenous methylprednisolone for 3 days, followed by oral prednisolone. The optic neuritis recurred following initial cessation of steroids requiring an extended course of steroids. Despite this, she made a good visual recovery to 6/6 in the affected eye. We present this case and a review of the literature surrounding vaccination and the development of these conditions.

A Multisite Preregistered Paradigmatic Test of the Ego-Depletion Effect

We conducted a preregistered multilaboratory project (k = 36; N = 3,531) to assess the size and robustness of ego-depletion effects using a novel replication method, termed the paradigmatic replication approach. Each laboratory implemented one of two procedures that was intended to manipulate self-control and tested performance on a subsequent measure of self-control. Confirmatory tests found a nonsignificant result (d = 0.06). Confirmatory Bayesian meta-analyses using an informed-prior hypothesis (δ = 0.30, SD = 0.15) found that the data were 4 times more likely under the null than the alternative hypothesis. Hence, preregistered analyses did not find evidence for a depletion effect. Exploratory analyses on the full sample (i.e., ignoring exclusion criteria) found a statistically significant effect (d = 0.08); Bayesian analyses showed that the data were about equally likely under the null and informed-prior hypotheses. Exploratory moderator tests suggested that the depletion effect was larger for participants who reported more fatigue but was not moderated by trait self-control, willpower beliefs, or action orientation.

P36: SOMATIC SYMPTOM DISORDER (SSD) AND ABDOMINAL PAIN: INCREASED OPIOID PRESCRIBING IN SURGICAL PATIENTS

Introduction

Undifferentiated pain, and pain out of proportion of diagnosed pathology are sources of frustration to clinician and patient. SSD is a DSM-V diagnosis that has consolidated the previous diagnoses of psychogenic pain. It is a health anxiety condition, where sufferers experience multiple somatic symptoms which cause anxiety and distress. This anxiety results in frequent ED and GP presentations, extensive investigations, and increased opioid prescription. However, opioids do little to alleviate symptoms. Treatment should focus on underlying anxiety and depression.

Population studies show SSD prevalence to be 15-20%, however SSD has never been studied in the surgical population. We hypothesized that the rates of SSD in the surgical population reflects that in primary care, and that SSD sufferers are more likely to be prescribed opioid analgesia.

Method

Adult patients admitted with abdominal pain of any non-traumatic aetiology to the Acute General Surgical Unit at a major tertiary hospital are being screened for SSD using the PHQ-15 questionnaire, and opioid prescription is being recorded.

Result

400 participants have been recruited with a total SSD prevalence of 20%. Opioid prescribing rises sharply with SSD diagnosis. The average opioid prescription appears to be 3 times higher in patients with SSD compared to those without.

Conclusion

Our data confirms an SSD prevalence of 20% in the surgical population. This is associated with increased opioid prescription. Early recognition of SSD and implementation of appropriate treatment could reduce hospital presentations, admissions and opioid prescription. We will continue recruitment to 800 participants by March 2020.

Take-home message

SSD is common in all populations, and results in increased hospital presentations, admissions and opioid prescription. Early recognition and implementation of appropriate treatment may reduce healthcare burden, improve patient outcomes, and reduce opioid prescription.

The Canadian Neuromuscular Disease Registry 2010-2019: A Decade of Facilitating Clinical Research Througha Nationwide, Pan-NeuromuscularDisease Registry

We report the recruitment activities and outcomes of a multi-disease neuromuscular patient registry in Canada. The Canadian Neuromuscular Disease Registry (CNDR) registers individuals across Canada with a confirmed diagnosis of a neuromuscular disease. Diagnosis and contact information are collected across all diseases and detailed prospective data is collected for 5 specific diseases: Amyotrophic Lateral Sclerosis (ALS), Duchenne Muscular Dystrophy (DMD), Myotonic Dystrophy (DM), Limb Girdle Muscular Dystrophy (LGMD), and Spinal Muscular Atrophy (SMA). Since 2010, the CNDR has registered 4306 patients (1154 pediatric and 3148 adult) with 91 different neuromuscular diagnoses and has facilitated 125 projects (73 academic, 3 not-for-profit, 3 government, and 46 commercial) using registry data. In conclusion, the CNDR is an effective and productive pan-neuromuscular registry that has successfully facilitated a substantial number of studies over the past 10 years.

Rational Selection of Patient-Reported Outcomes Measures in Lumbar Spine Surgery Patients

Background

The Short Form-12 (SF-12) was developed as a shorter version of the SF-36, yet there has been limited validation of its reliability at measuring postoperative changes. The purpose of this study was to determine if the SF-12 could safely substitute for the SF-36 in measuring postoperative change in lumbar spine surgery patients and if the condition specific (Oswestry Disability Index [ODI]) or pain (visual analog scale [VAS]) instruments, provided additional utility.

Methods

A total of 972 patients from a single center who underwent lumbar spine surgery for a predominant symptom of radiating leg pain with (n = 237) or without (n = 735) fusion and prospectively completed both SF-36 and ODI instruments before and after surgery were included. The SF-12 score was calculated from the appropriate subset of SF-36 responses. The absolute sensitivity and the intraclass correlation coefficient were calculated. Reliability of each instrument to measure preoperative to postoperative change was calculated as the standardized response mean.

Results

The SF-12 and SF-36 demonstrated a strong correlation with each other ([0.97, P < .001] and [0.93, P < .001], respectively) preoperatively and postoperatively. The SF-12 and SF-36 scores were moderately to strongly inversely correlated with the ODI. The ODI showed greater reliability at measuring change than the SF-12 for both fusion (0.94 versus 0.72) and nonfusion (0.81 versus 0.33) lumbar surgery patients.

Conclusions

The SF-12 was as effective as the SF-36 to measure general health status in lumbar spine surgery patients, and both were moderate to strong predictors of ODI preoperatively and postoperatively, but lack the reliability to detect change seen with the ODI or VAS after surgical intervention.

Level of Evidence

3.

Clinical Relevance

These data suggest that the SF-12 is a valid substitute for the SF-36 to measure postoperative outcomes changes, but that the ODI should continue to be used to measure condition specific changes in function.

Setting the research agenda for living with and beyond cancer with comorbid illness: reflections on a research prioritisation exercise

BACKGROUND

People living with and beyond cancer are more likely to have comorbid conditions and poorer mental and physical health, but there is a dearth of in-depth research exploring the psychosocial needs of people experiencing cancer and comorbid chronic conditions. A patient partnership approach to research prioritisation and planning can ensure outcomes meaningful to those affected and can inform policy and practice accordingly, but can be challenging.

METHODS

We aimed to inform priorities for qualitative inquiry into the experiences and support needs of people living with and beyond cancer with comorbid illness using a partnership approach. A three-step process including a patient workshop to develop a consultation document, online consultation with patients, and academic expert consultation was carried out. The research prioritisation process was also appraised and reflected upon.

RESULTS

Six people attended the workshop, ten responded online and eight academic experts commented on the consultation document. Five key priorities were identified for exploration in subsequent qualitative studies, including the diagnostic journey, the burden of symptoms, managing medications, addressing the needs of informal carers, and service provision. Limitations of patient involvement and reflections on procedural ethics, and the challenge of making measurable differences to patient outcomes were discussed.

CONCLUSIONS

Findings from this research prioritisation exercise will inform planned qualitative work to explore patients' experiences of living with and beyond cancer with comorbid illness. Including patient partners in the research prioritisation process adds focus and relevance, and feeds into future work and recommendations to improve health and social care for this group of patients. Reflections on the consultation process contribute to a broadening of understanding the field of patient involvement.

Neonatal outcomes following previable prelabour rupture of membranes before 23 weeks of gestation - A retrospective cohort study

OBJECTIVE

To compare outcomes of hospitalized preterm infants following previable prelabour rupture of membranes (PPROM) at≤23 weeks of gestation.

METHODS

Retrospective cohort study of preterm infants admitted for intensive care, between January 2006 and December 2016 following PPROM, was conducted. Short term clinical outcomes included severity of respiratory morbidity, length of hospital stay and mortality. Neurodevelopment in survivors was assessed using Bayley's Scales of Infant Development (3rd edition) at 24 months corrected age.

RESULTS

A total of 82 preterm infants were admitted following PPROM at < 23 weeks and were grouped as: Group 1 (n = 28) with PPROM < 20 weeks and Group 2 (n = 54) with PPROM between 20-22 + 6 weeks. Median latency following PPROM was significantly longer in Group 1 infants [69(Interquartile range (IQR): 43-74; Range (R): 25-100 vs. 29(IQR: 10-53; R: 2-72) days, p < 0.001]. Median gestation at delivery was 27.4 weeks (Group 1) vs. 25.1 weeks (Group 2). Group 1 had a significantly higher incidence of oligohydramnios [13(46.4%) vs. 8(14.8%), p = 0.002], lower Apgar scores (<7) at 5 minutes [19(67.9%) vs. 24(44.4%), p = 0.044], increased pulmonary hypoplasia [13(46.4%) vs. 5(9.3%), p < 0.001], joint contractures [3(10.7%) vs. 0, p = 0.037] and mortality [10(35.7%) vs. 7(13.0%), p = 0.016]. Neurodevelopmental outcomes at 24 months corrected age were comparable in the 36 surviving infants (9/18 vs. 27/547).

CONCLUSION

Morbidity and mortality is high in infants born after previable PPROM; specifically, in those with PPROM < 20 weeks although early childhood neurodevelopmental outcomes were comparable. Larger prospective studies focussing on long term neonatal outcomes are needed to confirm these findings.

Comparison of the Reveal 20-Hour Method and the BAM Culture Method for the Detection of Escherichia coli O157:H7 in Selected Foods and Environmental Swabs: Collaborative Study

Four different food types along with environmental swabs were analyzed by the Reveal for E. coli O157:H7 test (Reveal) and the Bacteriological Analytical Manual (BAM) culture method for the presence of Escherichia coli O157:H7. Twenty-seven laboratories representing academia and private industry in the United States and Canada participated. Sample types were inoculated with E. coli O157:H7 at 2 different levels. Of the 1095 samples and controls analyzed and confirmed, 459 were positive and 557 were negative by both methods. No statistical differences (p &lt;0.05) were observed between the Reveal and BAM methods.

Reveal 8-Hour Test System for Detection of Escherichia coli O157:H7 in Raw Ground Beef, Raw Beef Cubes, and Iceberg Lettuce Rinse: Collaborative Study

Five different food types were analyzed by the Reveal for E. coli O157:H7 8-Hour Test System (Reveal 8) and either the U.S. Food and Drug Administration's Bacteriological Analytical Manual (BAM) culture method or the U.S. Department of Agriculture Food Safety Inspection Service (FSIS) culture method for the presence of E. coli O157:H7. A total of 27 laboratories representing academia and private industry in the United States and Canada participated. Food types were inoculated with E. coli O157:H7 at 2 different levels: a high level where predominantly positive results were expected, and a low level where fractional recovery was anticipated. During this study, 1110 samples and controls were analyzed by both the Reveal 8 and by BAM or FSIS by each of the collaborators (2220 samples in total). For each set of samples, 740 were artificially inoculated with E. coli O157:H7, and 370 were uninoculated controls. The Reveal 8 detected 528 presumptive positives of which 487 were confirmed positive by the BAM culture method. In comparison, BAM and FSIS detected 489 of the 740 artificially contaminated samples as positive. In an additional in-house study performed only on chilled and frozen raw ground beef, 240 artificially inoculated samples were analyzed by both the Reveal 8 and by FSIS. The Reveal 8 detected and confirmed 104 samples as positive compared to 79 confirmed positive by FSIS.

Abstract P4-13-13: Meta-analyses of visceral versus non-visceral metastases treated by AI & SERD agents as 2nd line endocrine therapy (ET) for HR+ breast cancer (BC)

There is a prevailing belief that ET for HR+ advanced BC is not as effective in patients with visceral metastases (VM) compared to non-visceral metastases (nVM), particularly with later lines of ET. Recently fulvestrant 500mg (Ful 500), has been reported to have greater efficacy in nVM compared to i) VM treated by Ful 500 but also compared to ii) nVM treated by Ful 250 (2nd line) and iii) nVM treated by aromatase inhibitor (AI), anastrozole (1st Line) – implying both site and agent related efficacy. Absence of significant overall survival (OS) difference in PALOMA 3 (2nd line) has increased the debate regarding when to add CDK 4/6is to ET, especially given the OS advantage for Ful 500 monotherapy in the 1st & 2nd line settings.

Patients & Methods: Anonymised, individual patient level data was obtained from randomised controlled trials (RCTs) involving AI & SERD used as mono-theraphy in 2nd or 3rd Line setting in known HR+ BC. All the trials were Phase 3 double-blind, placebo RCTs. All were rigorously assessed for clinical benefit (CB), progression free survival (PFS), duration of CB (DoCB) and OS. Details of the studies, types of ET and patient numbers are shown in the Table.

Results: Outcome data is presented for each study and then summarised under AI, SERD (Ful 250 or 500) and 'all Ets combined'. Odds ratios (Ors) & hazard ratios (HRs) for VM versus nVM by endocrine agents are shown in the Table.

AgentStudyTotal Pats.HR+ Pats.CBRPFSOSDoCBAI(n)(n)OR (95%Cis)HR (95%Cis)HR (95%Cis)HR (95%Cis)Exe00202301831.181.441.271.50Exe00211931681.151.951.832.12AnaEFECT3403360.941.521.201.10AnaSOFEA2492491.291.181.051.41subtotal7636871.11 (0.84-1.48)1.47*** (1.22-1.79)1.21* (1.01-1.45)1.43** (1.10-1.86)SERDFul 25000202191601.791.701.401.23Ful 25000212041771.281.811.322.06Ful 250EFECT3513450.791.401.311.03Ful 250SOFEA2312310.701.171.242.22Ful 250CONFIRM1521521.131.071.510.84Subtotal9268341.05 (0.75-1.45)1.39*** (1.16-1.67)1.34*** (1.14-1.57)1.36 (0.93-1.98)SERDFul 500CONFIRM1441442.24 (1.12-4.48)1.30 (0.90-1.87)1.33 (1.14-1.57)0.97 (0.55-1.66)All ETsTotal183316651.13 (0.92-1.39)1.42*** (1.26-1.59)1.28*** (1.14-1.44)1.35** (1.09-1.66)

[Pats=Patients; (n)=number; CBR-Clinical Benefit Rate; p-values p&lt;0.05*, p&lt;0.01**, p&lt;0.001***]

Median PFS (months) for nVM for AI, SERD250, SERD500 & ‘all Ets combined’ were 5.4, 5.5, 11.0 & 5.5 respectively: for VM they were 2.9, 3.5, 5.5 & 3.2 respectively.

Median OS (months) for nVM for AI, SERD250, SERD500 & ‘all Ets combined’ was 24.2, 26.0, 35.4 & 25.4 respectively: for VM the figures were 22.8, 20.8, 26.4 & 22.0 respectively.Conclusions:1) In the 2nd line HR+ setting AI & Ful 250 both significantly increased PFS & OS in nVM versus VM. Longer PFS appears due to longer duration of control (DoCB) than increasing the number of patients responding (CBR).

2) Median OS for nVM ranged from 24 – 35 months versus 20.8-26.4 months for VM: for the majority of patients the 2nd line ET setting is not ‘immediately life threating’ and ET is therefore an option to consider.

3) These data on site of disease (nVM vs VM) contribute to the selection of which patients should receive endocrine mono- and which endocrine combination therapy (ie plus mTORi or CDK4/6i) in the second line setting.

Citation Format: Robertson JFR, Di Leo A, Johnston S, Chia S, Bliss J, Bradbury I, Campbell C. Meta-analyses of visceral versus non-visceral metastases treated by AI & SERD agents as 2nd line endocrine therapy (ET) for HR+ breast cancer (BC) [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P4-13-13.

Abstract P4-13-11: Meta-analyses of visceral versus non-visceral metastases treated by SERM, AI & SERD agents as 1st line endocrine therapy (ET) for HR+ breast cancer (BC)

Introduction: There is continuing debate whether efficacy of ET is different in non-visceral metastases (nVM) than VM. Recently fulvestrant 500mg, has been reported to have greater efficacy than an aromatase inhibitor (AI), anastrozole, particularly in nVM – implying efficacy may be both site and agent dependent. Absence of significant overall survival (OS) difference in PALOMA 1 & 3 has increased interest in site of disease, especially given the OS advantage for fulvestrant 500mg monotherapy.

Patients & Methods: Individual patient level data was obtained from 7 randomised controlled trials (RCTs) involving SERM, AI & SERD used as 1st Line ET in known HR+ BC were used in this meta-analysis (MA). Five were Phase 3 double-blind, placebo controlled RCTs. Details of the studies, type of ET and patient numbers are shown in Table. All were rigorously assessed for clinical benefit rate (CBR), progression free survival (PFS), duration of clinical benefit (DoCB) and OS.: Details of the studies, types of ET and patient numbers are shown in the Table. Aa two stage MA IPD meta-analysis was used to analyse these outcomesCBR, PFS, OS & DoCB. Peto method for pooled odds ratios was used to calculate p values and CI for CBR, yYusef pPeto method was used to calculate p-values and CI for PFS, OS, and DoCB. Random effect for trial was included when Tarone's test for heterogeneity was significant, otherwise fixed effect models were generated.

Results:

Outcome data is present for each study and then summarised under SERM, AI, SERD and 'all Ets combined'. Odds Ratios (Ors) & Hazard Ratios (HRs) for VM versus nVM by endocrine agent are shown in the Table

ETStudyNo. of Pats.HR+ Pats.CBRPFSOSDoCBSERM(n)(n)OR (95%CIs)HR (95%CIs)HR (95%CIs)HR (95%CIs)TamEORTC1891781.410.850.770.95Tam00273281441.330.981.051.26Tam00301821622.800.590.440.79Tam00252742091.100.780.730.78subtotal9736931.53** (1.11-2.10)0.79** (0.67-0.94)0.70* (0.52-0.94)0.92 (0.72-1.18)AIExeEORTC1821680.841.110.731.02Ana00273401543.850.550.361.06Ana00301711510.970.881.140.82AnaFALCON2322321.070.980.831.05AnaFIRST1031030.970.540.510.53Subtotal10288081.28 (0.73-2.22)0.80 (0.60-1.06)0.66* (0.45-0.95)0.92 (0.74-1.14)SERDFul 500CONFIRM1621622.940.630.561.15Ful 500FALCON2302302.710.410.450.61Ful 500FIRST1021024.110.580.440.55Subtotal4944943.06*** (2.00-4.06)0.56*** (0.45-0.70)0.50*** (0.39-0.65)0.71* (0.53-0.91)Total249519981.66*** (1.37-2.02)0.73*** (0.62-0.86)0.61*** (0.53-0.71)0.87* (0.75-1.00)CBR-Clinical Benefit Rate (n)= number of patients, pvalues p&lt;0.05*, p&lt;0.01**, p&lt;0.001***

Conclusions: This is the largest reported individual patient MA for nVM versus VM in patients with known HR+ advanced BC and clinical outcomes (CBR, DoCB, PFS & OS) approved to regulatory standards.

1) nVM had significantly better clinical outcomes compared to VM when treated by anti-estrogen receptor blocking agents (SERM & SERD) but not when treated by Ais, which have a fundamentally different mechanism of action.

2) SERD (Fulvestrant 500mg) significantly increased all four clinical outcomes. For nVM compared to VM, fulvestrant put more patients into CB, kept them in remission (DoCB) for longer, resulting in 44% reduction in disease progression and a 50% reduction in death.

3) Site of metastases (ie nVM or VM) is one of the factors to consider when selecting patients for endocrine mono or combination ET (plus CDK4/6i) in the 1st Line setting.

Citation Format: Robertson JFR, Paridaens R, Bogaerts J, Lichfield J, Bradbury I, Campbell C. Meta-analyses of visceral versus non-visceral metastases treated by SERM, AI & SERD agents as 1st line endocrine therapy (ET) for HR+ breast cancer (BC) [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P4-13-11.

A Systematic Review of Health System Level Initiatives Promoting the Earlier Diagnosis of Cancer Among the Adult Population in High-Income Countries

Background: The increased burden of cancer has driven the development of health system level initiatives worldwide promoting early diagnosis. Although it is challenging to synthesize results of such complex, diverse initiatives, it is crucial to review the evidence to inform future programs and enhance transparency and accountability. Aim: We aimed to systematically review the literature on health system level initiatives promoting early diagnosis among the adult population, describing and categorizing their components, stakeholders, target populations, and outcomes. Methods: We have searched databases (including Embase, PsycInfo, Medline and ASSIA), Web sites (including charities, governmental and nongovernmental agencies) and reference lists of included studies and relevant systematic reviews for peer-reviewed publications and gray literature. We included quantitative, qualitative, mixed-methods studies and reviews/overviews about a single initiative in high-income countries as defined by the World Bank. We included initiatives: 1) targeting adults aged 18 or older; 2) aiming to promote early diagnosis; 3) addressing the patient/public and at least two more levels of contextual influence (according to a model of multilevel influences on cancer care); 4) implemented at a national level or equivalent. Study selection, quality assessment and data extraction were carried out independently by two reviewers. Narrative synthesis was used to analyze the findings. The review protocol has been published by BMJ Open and registered at PROSPERO (CRD42016047233). Results: Twenty initiatives from 10 countries were identified in 263 publications. Data were extracted from 104 core publications about 19 initiatives. It was possible to assess the quality of 35 core publications. Initiatives focused on fast-track for patients with alarm symptoms or other referral pathways for those with other symptoms or abnormal test results (n=11), national awareness campaigns for the public (n=4), and strategies with multiple components (n=4). Tools developed for professionals included referral guidelines and online referral systems. Initiatives focusing on referral pathways showed some improvements in diagnostic intervals, and limited evidence on the impact on staging. Performance targets were often not met. Results from awareness campaigns indicated improvement in awareness, but evidence about changes in health-seeking behavior was limited. Barriers and facilitators were described, including availability of specialist staff. Conclusion: Robustness of methods/outcomes could not always be assessed as several publications were reports or government documents. Evidence on the impact of initiatives regarding longer-term outcomes is limited. Described barriers and facilitators may help to inform future initiatives. Findings may be useful to researchers, policy makers, and governments developing early diagnosis programs and assessing cancer outcomes.

Use of Thermocoagulation Within a 'Screen and Treat' Cervical Cancer Screening Programme in Malawi: Outcomes at One Year, Professional Perspectives, and Client Experience

Background: Thermocoagulation (also known as thermoablation, previously as cold coagulation) is increasingly being adopted as an alternative treatment to cryotherapy within 'screen and treat' cervical screening services using visual inspection with acetic acid (VIA) in resource-constrained settings. This ablative treatment is suitable for low-grade squamous epithelial lesions. Given that much of the current systematic review evidence is drawn from high-income settings, it is critical that the evidence base for use within LMICs is strengthened. Aim: To evaluate the effectiveness of thermo-coagulation in the treatment of VIA-positive lesions within a 'screen and treat' program in Malawi, and its acceptability to clients and providers. Methods: Over the last four years, the Nkhoma Cervical Cancer Screening Program has implemented a 'screen and treat' approach using VIA and treatment using thermocoagulation in a rural district general hospital and associated health centers. Women with VIA-positive lesions are offered treatment with thermocoagulation; treated women are requested to return for review at three- six months, and at one year. Mechanisms to ensure monthly data collection and collation are in place. Semistructured qualitative face-to-face interviews were carried out in English with nineteen providers in nine health centers associated with Nkhoma Hospital: a range of issues were explored, including their experience with use of thermocoagulation. A patient experience questionnaire using validated facial pain scales was developed and translated into Chichewa: women complete this following treatment together with a patient attendant. Results: Between October 2013 and July 2017, over 1650 women have received treatment with thermocoagulation. Of a cohort of 446 treated women who had returned for a 1-year review visit by July 2017, 426 (95.5%) were VIA-negative, i.e., a treatment failure rate of < 5%, comparable with the international literature. Relationship between HIV status, initial VIA positivity, and treatment outcomes, will be presented. Staff reported professional satisfaction in being able to offer treatment consistently to VIA-positive clients, closer to their communities. For some, this was contrasted with previous experience of unavailable cryotherapy resulting in loss to treatment of patients. Over 120 women have completed pain scales questionnaires following treatment with the traditional machine, or with one of the two new hand-held models: their experiences (facial pain scales, and free-text comments) will be reported. Conclusion: In many low-resource settings, VIA-based screening with robust treatment protocols will remain central to cervical cancer control until the promise of HPV vaccination is fully realized. Thermocoagulation is an effective treatment modality, acceptable to clients and patients. Ongoing review of outcomes within and across treatment facilities is critical.

The Experience of Living With and Beyond Cancer With Comorbid Illness: A Qualitative Systematic Review

Background: There is a need to explore the needs of the growing number of people living with and beyond cancer with additional long term chronic conditions, with implications for cancer survivorship management and support. Aim: This review aims to identify the qualitative evidence on the experience of cancer and comorbid illness from the perspective of patients, carers and health care professionals to identify psycho-social support needs, experience of health care, and to highlight areas where more research is needed. Methods: PRISMA guidance was used to review the evidence. Relevant research databases were searched using an exhaustive list of search terms. Two reviewers independently screened titles and abstracts and discussed variations. Included articles were subject to quality appraisal before data extraction of article characteristics and findings. Thematic synthesis of extracted findings was undertaken following Thomas and Harden's prescribed method. Results: 29 articles were included in the review covering a range of cancer types and comorbid conditions; with varying time since cancer diagnosis and apparent severity of disease for both cancer and other conditions. Studies are set in developed countries and include the views of patients and professionals but not carers. Few studies focused exclusively on the experience of living with comorbid conditions alongside cancer. Key themes identified included: the interaction between cancer and comorbid conditions; the added symptom burden; illness identities and ageing; self-management; prioritizing conditions, and treatment decision-making. Conclusion: In addition to a better understanding of the complex experience of such illness to illuminate developing models of patient-centered care, the review will combine with patient engagement work to inform an interview study with the defined patient group.

Second Primary Cancers (SPC): A Mixed-Methods Systematic Review of Pathways to Diagnosis and a National Linkage Study in Scotland to Understand Survival Outcomes Following an SPC Diagnosis

Background: As an increasing proportion of patients survive an initial cancer, the number who develop a second primary cancer (SPC) is also increasing. Aim: To examine the pathways to diagnosis of an SPC and the associated patients' and health practitioners' experiences, and survival outcomes following an SPC diagnosis. Methods: We conducted a systematic review to examine the pathways to diagnosis and associated patient and healthcare practitioners' experiences. Ten electronic databases were searched with no date or language restrictions. Two reviewers independently screened titles, abstracts and full-texts, and did the data extraction and quality assessment of the included studies. Secondary data analysis examined the survival outcomes following an SPC diagnosis. This involved three linked databases: the Scottish Cancer Registry, episode level data on hospital inpatient and day case discharges, and the National Register of Scotland death records. We included patients aged 18+, diagnosed with a first primary cancer (FPC) between 01.01.1980 and 31.12.2010 and subsequently diagnosed with an SPC (> 60 days following a FPC). The cases were matched for age, gender and cancer type to controls (individuals diagnosed with an FPC only within the same 5-year period). Descriptive statistics, survival analysis and Cox proportional hazard model were done. Results: Forty-nine articles were included in the review. The most commonly reported SPCs were breast, lung, colorectal, and melanoma. All included studies reported on the mode of detection of the SPC (30 symptomatic presentation, 18 screen detected, 34 other modes). The routes to detection (whether the SPC was diagnosed during routine follow-up/surveillance, or self-referral) varied by cancer type. Only two studies described provider experiences of diagnosis of an SPC; no study reported on the patients' experiences. The secondary data analysis included 37,193 people diagnosed with an SPC (51.6% females and 48.3% male). The proportion of SPC among people diagnosed with a FPC within a 5-year period ranged between 2.3% (1980-1985) and 31.2% (2006-2010). Trachea, bronchus and lung cancer (21.3%), colorectal cancer (13.9%), breast (12.9%) and prostate (7.3%) were the most frequently diagnosed SPCs in this population. These four cancers also accounted for the highest number of deaths in both sexes. Compared with people diagnosed with FPC (390 days: IQR 14-1825 days), those diagnosed with SPC had shorter median survival days (379 days: IQR 17-1825 days), which was statistically significant ( P = 0.001, X24df=163.2). Conclusion: The review provides early insights into diagnosis of an SPC. While it has identified that there is a dearth of quantitative and qualitative evidence on the pathways to diagnosis of an SPC, the secondary data analysis partly fills the gap, and has important implications for surveillance in both primary and secondary care, and secondary prevention and early detection.