Adjusted estimate of the prevalence of hepatitis delta virus in 25 countries and territories

BACKGROUND & AIMS

Hepatitis delta virus (HDV) is a satellite RNA virus that requires the hepatitis B virus (HBV) for assembly and propagation. Individuals infected with HDV progress to advanced liver disease faster than HBV-monoinfected individuals. Recent studies have estimated the global prevalence of anti-HDV antibodies among the HBV-infected population to be 5-15%. This study aimed to better understand HDV prevalence at the population level in 25 countries/territories.

METHODS

We conducted a literature review to determine the prevalence of anti-HDV and HDV RNA in hepatitis B surface antigen (HBsAg)-positive individuals in 25 countries/territories. Virtual meetings were held with experts from each setting to discuss the findings and collect unpublished data. Data were weighted for patient segments and regional heterogeneity to estimate the prevalence in the HBV-infected population. The findings were then combined with The Polaris Observatory HBV data to estimate the anti-HDV and HDV RNA prevalence in each country/territory at the population level.

RESULTS

After adjusting for geographical distribution, disease stage and special populations, the anti-HDV prevalence among the HBsAg+ population changed from the literature estimate in 19 countries. The highest anti-HDV prevalence was 60.1% in Mongolia. Once adjusted for the size of the HBsAg+ population and HDV RNA positivity rate, China had the highest absolute number of HDV RNA+ cases.

CONCLUSIONS

We found substantially lower HDV prevalence than previously reported, as prior meta-analyses primarily focused on studies conducted in groups/regions that have a higher probability of HBV infection: tertiary care centers, specific risk groups or geographical regions. There is large uncertainty in HDV prevalence estimates. The implementation of reflex testing would improve estimates, while also allowing earlier linkage to care for HDV RNA+ individuals. The logistical and economic burden of reflex testing on the health system would be limited, as only HBsAg+ cases would be screened.

IMPACT AND IMPLICATIONS

There is a great deal of uncertainty surrounding the prevalence of hepatitis delta virus among people living with hepatitis B virus at the population level. In this study, we aimed to better understand the burden in 25 countries and territories, to refine techniques that can be used in future analyses. We found a lower prevalence in the majority of places studied than had been previously reported. These data can help inform policy makers on the need to screen people living with hepatitis B virus to find those coinfected with hepatitis delta virus and at high risk of progression, while also highlighting the pitfalls that other researchers have often fallen into.

Study protocol for The GOAL Trial: comprehensive geriatric assessment for frail older people with chronic kidney disease to increase attainment of patient-identified goals-a cluster randomised controlled trial

BACKGROUND

An increasing number of older people are living with chronic kidney disease (CKD). Many have complex healthcare needs and are at risk of deteriorating health and functional status, which can adversely affect their quality of life. Comprehensive geriatric assessment (CGA) is an effective intervention to improve survival and independence of older people, but its clinical utility and cost-effectiveness in frail older people living with CKD is unknown.

METHODS

The GOAL Trial is a pragmatic, multi-centre, open-label, superiority, cluster randomised controlled trial developed by consumers, clinicians, and researchers. It has a two-arm design, CGA compared with standard care, with 1:1 allocation of a total of 16 clusters. Within each cluster, study participants ≥ 65 years of age (or ≥ 55 years if Aboriginal or Torres Strait Islander (First Nations Australians)) with CKD stage 3-5/5D who are frail, measured by a Frailty Index (FI) of > 0.25, are recruited. Participants in intervention clusters receive a CGA by a geriatrician to identify medical, social, and functional needs, optimise medication prescribing, and arrange multidisciplinary referral if required. Those in standard care clusters receive usual care. The primary outcome is attainment of self-identified goals assessed by standardised Goal Attainment Scaling (GAS) at 3 months. Secondary outcomes include GAS at 6 and 12 months, quality of life (EQ-5D-5L), frailty (Frailty Index - Short Form), transfer to residential aged care facilities, cost-effectiveness, and safety (cause-specific hospitalisations, mortality). A process evaluation will be conducted in parallel with the trial including whether the intervention was delivered as intended, any issue or local barriers to intervention delivery, and perceptions of the intervention by participants. The trial has 90% power to detect a clinically meaningful mean difference in GAS of 10 units.

DISCUSSION

This trial addresses patient-prioritised outcomes. It will be conducted, disseminated and implemented by clinicians and researchers in partnership with consumers. If CGA is found to have clinical and cost-effectiveness for frail older people with CKD, the intervention framework could be embedded into routine clinical practice. The implementation of the trial's findings will be supported by presentations at conferences and forums with clinicians and consumers at specifically convened workshops, to enable rapid adoption into practice and policy for both nephrology and geriatric disciplines. It has potential to materially advance patient-centred care and improve clinical and patient-reported outcomes (including quality of life) for frail older people living with CKD.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04538157. Registered on 3 September 2020.

Is Online Video-Based Education an Effective Method to Teach Basic Surgical Skills to Students and Surgical Trainees? A Systematic Review and Meta-analysis

BACKGROUND

Online education has been increasingly utilized over the past decades. The COVID-19 pandemic accelerated the transition of conventional face-to-face curricula to online platforms, with limited evidence for its teaching efficacy. This systematic review aims to assess the effectiveness of online video-based education compared with standard conventional education in teaching basic surgical skills to surgical trainees and students undergoing medical training.

METHODS

We performed a literature search in Embase, Medline, Cochrane CENTRAL and Scopus from inception until February 2022. Studies included were randomised controlled trials (RCTs) and observational studies. We included randomised controlled trials only for meta-analysis. The primary outcome was surgical skill proficiency. The secondary outcomes were participant perception, confidence and satisfaction. Two authors independently assessed the search results for eligibility, extracted the data and assessed the risk of bias using the Cochrane Risk of Bias tool 2. Where appropriate, we performed random effects meta-analyses of the pooled study data to calculate a standardized mean difference.

RESULTS

A total of 11 studies met the inclusion criteria totaling 715 participants; 603 were included in qualitative analysis and 380 in meta-analysis. All included studies were assessed as having a low risk of bias. The majority of studies found no significant difference between conventional and video-based education in teaching basic surgical skills, three studies found video-based education was superior and one study found conventional education was superior. There was no statistically significant difference in skill proficiency between the two groups (standardized mean difference of -0.02 (95% CI: -0.34, 0.30); p=0.90). Video-based education results in an equivalent improvement in confidence and satisfaction rates. Additional benefits of video-based education include convenience, accessibility and efficiency.

CONCLUSIONS

Basic surgical skills can be taught as effectively through online video-based education as conventional teaching methods. Online education should be utilized as an adjunct to medical curricula beyond the COVID-19 era.

Reducing health inequalities through general practice in the UK: a realist review (EQUALISE)

Background

In the UK, chronic conditions such as cancer, heart disease, stroke, and chronic obstructive pulmonary disease are driving health inequalities in life expectancy and were responsible for two-thirds of premature mortality in 2017. Voices that stress the importance of primary care in reducing health inequalities have been strengthening during the last decade. However, defining the most effective strategies to reduce health inequalities through general practice remains a challenge.

Aims

This study examines the evidence on interventions in primary care that are likely to decrease inequalities in NCDs and especially cancer, diabetes, cardiovascular and chronic obstructive pulmonary disease and will provide healthcare organisations with guiding principles on what should be commissioned.

Methods

The study is a realist review following Pawson's model. Based on a programme theory, we screened systematic reviews of interventions delivered in primary care and through their references, we identified primary studies reporting on inequalities across PROGRESS-Plus criteria. The data were analysed in light of the initial program theory and organised in a model informed by Collins’ Domains of Power framework.

Results

Out of 251 included reviews we retrieved 6,555 primary studies which resulted in 333 studies for data extraction. We found that there are five guiding principles operating simultaneously across four different domains which can reduce health inequalities in General Practice. The principles include flexibility, continuity, inclusivity, intersectionality, and community and operate simultaneously across the domains of structures and policies; narratives and ideas; rules and practices; and relationships and experience.

Conclusions

Flexibility, continuity, inclusivity, intersectionality, and community are the five principles which should guide the design and delivery of General Practice for the reduction of health inequalities.

Key messages

• Flexibility, continuity, inclusivity, intersectionality, and community are the five principles which should guide the design and delivery of General Practice for the reduction of health inequalities.

• Action to reduce health inequalities should be taken simultaneously across the domains of structures and policies; narratives and ideas; rules and practices; and relationships and experience.

Association of malnutrition with in-hospital and long-term outcomes among ST-elevation myocardial infarction patients receiving primary PCI

Background

The impact of malnutrition on outcomes in a contemporary ST-segment-elevation myocardial infarction (STEMI) population is unclear. We hypothesized that malnutrition severity amongst STEMI patients undergoing primary percutaneous coronary intervention (pPCI) is associated with worse long-term outcomes.

Purpose

The aim of this study was 2-fold: 1) to establish the prevalence of malnutrition among STEMI patients undergoing pPCI; 2) to determine the association of malnutrition severity on in-hospital and 1-year outcomes in STEMI patients receiving pPCI

Methods

We retrospectively identified 1,169 STEMI patients of age ≥65 years who had received pPCI (2013–2020). Patients who had presented with out-of-hospital cardiac arrest or those who received fibrinolytic therapy were excluded. The Controlling Nutritional Status (CONUT) score, based on serum albumin, total cholesterol and lymphocyte count, was used as a tool to assess the nutritional status of included patients. Malnourished patients were defined as those with a CONUT score of 5 to 12. To account for the impact of frailty, a frailty index (FI) was determined using the health deficit accumulation model (Table 1). The primary outcome was 1-year all-cause mortality. The secondary outcome was a composite of in-hospital heart failure, cardiogenic shock, re-infarction, major bleeding, stroke, and all-cause mortality. A multivariable model adjusting for baseline covariates, including frailty index score, was performed (Figure 1).

Results

Among 1,169 STEMI patients receiving pPCI, 315 (26.9%) were classified as malnourished. Malnourished patients were older (mean 77.4 vs. 76.0 years, p=0.009) and had a higher comorbidity burden. After multivariable adjustment, worsening malnutrition was associated with increased 1-year all-cause mortality (odds ratio [OR] = 1.29, p<0.001). Worsening malnutrition was also associated with a higher incidence of the in-hospital composite adverse outcome (OR = 1.12, p=0.003) and increased in-hospital all-cause mortality (OR=1.41, p<0.001).

Conclusion

Among STEMI patients receiving pPCI, 1 in 4 were malnourished. Malnutrition was associated with increased rate of in-hospital composite adverse outcome and worse long-term outcomes, even when accounting for frailty. Efforts to routinely identify malnourished STEMI patients and to implement best practices to reduce the risk of adverse events in this vulnerable population are warranted.

Funding Acknowledgement

Type of funding sources: None.

899 A Closed Loop Audit of Imaging Rate in Suspected Complicated Acute Diverticulitis

Aim

Diverticular disease is commonly encountered in western populations, with complicated acute diverticulitis potentially leading to significant morbidity and mortality. The National Institute for Health and Care Excellence (NICE) recommend imaging these patients within 24-hours of admission, which is essential to confirm diagnosis and guide further management. We aimed to audit the imaging rate in suspected complicated acute diverticulitis within our department and identify ways to improve this.

Method

Data were collected from all patients admitted from January to June 2021 with suspected complicated acute diverticulitis as defined by NICE. Patients with normal inflammatory markers were excluded. Electronic records were reviewed for evidence of imaging performed within 24-hours of hospital admission and the imaging rate was compared with the previous audit cycle.

Results

96 patients were admitted with suspected complicated acute diverticulitis. 83 patients had raised inflammatory markers. 76 (91.6%) of these had contrast computer tomography (CT) scans performed within 24-hours of admission. Of the 7 (8.4%) patients who did not undergo imaging within 24-hours, 3 had recent imaging suggestive of diverticular disease or diverticulitis, 2 were treated with antibiotics, 1 patient refused, and 1 had CT within 48-hours due to delays waiting for dialysis.

Conclusions

We have shown continued good compliance with NICE guidelines, though the imaging rate has declined slightly compared with the previous audit cycle (94.3%). In order to maintain and improve these standards, we will offer educational sessions within our department to underline the importance of timely imaging in this patient group and continue to audit our performance.

Incidence and Outcomes of Early Cancers After Kidney Transplantation

Outcomes of early cancers after kidney transplantation are not well-understood. We included recipients of first live and deceased donor kidney transplants who developed de novo cancers in Australia and New Zealand between 1980–2016. We compared the frequency and stage of specific cancer types that developed early (≤12-months) and late (>12-months) post-transplantation. Risk factors for death were evaluated using multivariable Cox regression analyses. Of 2,759 recipients who developed de novo cancer, followed-up for 40,035 person-years, 243 (8.8%) patients were diagnosed with early cancer. Post-transplant lymphoproliferative disease, urinary cancers and melanoma were the most common cancer types (26%, 18%, and 12%) and the majority were either in-situ or locally invasive lesions (55%, 84%, and 86%). Tumors arising early from the gastrointestinal and respiratory systems were uncommon but aggressive, with 40% presenting with metastatic disease at time of diagnosis. Overall, 32% of patients with early cancers died within a median of 4.7 months (IQR:0.6–16) post-diagnosis and 91% were cancer-related deaths. Older recipient and donor age were associated with an increased risk of all-cause death. Early cancers, though infrequent in kidney transplant recipients, are associated with poor outcomes, as nearly 1 in 3 died from cancer-related death; with majority of deaths occurring within 12-months of cancer diagnosis.

Can one-step nucleic acid amplification assay predict four or more positive axillary lymph node involvement in breast cancer patients: a single-centre retrospective study

BACKGROUND

One-step nucleic acid amplification (OSNA) assay is a proven, accurate, intraoperative method for the detection of lymph node (LN) metastases. The aim of this study was to assess if the total tumour load (TTL) as calculated by OSNA could be used to predict N2 stage disease, ie ≥4 LN containing metastases, in invasive breast cancer patients.

METHODS

Between 2011 and 2019 at St Richard's Hospital, Chichester, all macro-metastasis-positive OSNA cases for invasive breast cancer were retrospectively reviewed. The association between clinicopathological variables and ≥4 LNs containing metastases was analysed using regression analysis.

RESULTS

In total, 134 patients with positive sentinel lymph node (SLN) on OSNA undergoing axillary node clearance were analysed, 53% of whom had no further positive LN, 25% had ≥4 lymph nodes positive. TTL was calculated as the aggregate of cytokeratin-19 mRNA copy count of all SLN tissue analysed via OSNA. TTL ≥1.1×10⁵copies/μl and lymphovascular invasion (LVI) were both significant predictors of N2 stage disease on both univariate (TTL p=0.04, LVI p=0.005) and multivariate (TTL p=0.008, LVI p=0.039) regression analysis.

CONCLUSION

Our findings show that SLN TTL via intraoperative OSNA assay can predict four or more positive axillary LN involvement in invasive breast cancer. This is important in that it may be used intraoperatively by surgeons to decide on whether to proceed with a full axillary node clearance in order to stage the axilla. Further research is required to shape future guidance.

ProGlide venous closure device facilitates early ambulation following cryoablation of atrial fibrillation

Funding Acknowledgements

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

Background

Same-day discharge following atrial fibrillation (AF) ablation is increasingly common. ProGlide device suture-mediated vascular closure (PD) offers a technique that may expedite mobilisation following large-bore (>12F) venous access. The utility of PD closure following cryoablation of AF has not been reported.

Purpose

We sought to evaluate haemostasis and early ambulation outcomes in patients receiving the ProGlide compared with conventional techniques.

Methods

104 consecutive patients undergoing cryoballoon pulmonary vein isolation (PVI) for paroxysmal or persistent at a single high-volume institution were included. PVI was  performed via a standardised approach including sedation, ultrasound-guided vascular access for 14F Cryosheath and second 7F sheath, anticoagulation protocol, transeptal puncture, 28mm cryoballoon and nurse-led same-day discharge protocol. Haemostasis was achieved using the Perclose Proglide device (PD) in the 14F access point ("pre-closure" technique) plus 5 minutes manual pressure at the 7F sheath site. Alternatively, a figure-of-eight/Z-suture (ZS) was employed for closure according to operator preference. Protamine was used for heparin reversal in all patients. Safety outcomes of major bleeding, haematoma and minor bleeding were assessed. Time to ambulation (TTA), time to discharge (TTD), same-day discharge and complications at initial follow-up were measured.

Results

Overall, mean age was 64 ± 11 years, 65 (64%) were male and 52 (50%) of patients had paroxysmal AF, there were no significant differences between group demographics, with 31 patients (30%) in the PD group and 73 (70%) in the ZS group. All patients had uninterrupted oral anticoagulation throughout the periprocedural period. No major femoral bleeding complications requiring intervention occurred in either group. Haematomas occurred in none of the PD group compared with 2 (2.8%) in the ZS group. Incidence of minor bleeding was not significantly different between groups (PD: 3 [9.7%] vs ZS: 2 [2.7%], p = 0.155). Mean TTA was significantly shorter in the PD group (3.3 ± 1.1 vs 4.1 ± 1.7 hrs, p = 0.025). However, there was no significant difference in same-day discharge (PD: 25 [81%] vs ZS: 53 [73%], p = 0.386) and TTD (5.0 ± 3.6 vs 6.1 ± 4.2 hrs, p = 0.275) between groups. 1 patient complained of groin pain which delayed discharge in the ZS group not seen in the PD group. After a mean follow-up of 2.2 ± 1.4 months, there were no differences in major or minor complications.

Conclusion

Use of the Proglide closure device was associated with significant reductions in time to ambulation compared with Z-suture haemostasis following cryoablation of AF, and groin access complications were uncommon across groups.  PD closure may contribute to further streamlining patient pathways in day-case AF ablation.

Scrub sink contamination and transmission to operating room personnel

Multiple studies have established the contamination of hospital sinks and transmission to hospital personnel. Few studies have assessed the contamination and transmission of microorganisms from the faucets of operating bay scrub sinks to operating room (OR) personnel, a potential route of infection for patients. This study aimed to investigate if there was pathogenic contamination of scrub sinks and possible transmission of those pathogens to the hands of OR personnel after preoperative hand disinfection. Swabs were taken from the hands of 50 OR personnel and from the faucets of 24 scrubs sinks at two different hospital sites, and were cultured. Hands were swabbed after completing a surgical hand scrub. Results were reported in colony-forming units per millilitre. There was significant scrub sink contamination with primarily Gram-negative organisms, such as Delftia acidovorans and Sphingomonas paucimobilis. There was no overlap in bacterial species between the cultures from hands and scrub sinks. Cultures from the sinks and the hands of the OR personnel from one site had significantly higher bacterial growth compared with the other site (p < 0.0001 and p < 0.0118, respectively). The data showed significant contamination on the faucets of operating bay scrub sinks. However, there was no observed transmission of pathogens from the scrub sinks to OR personnel, shown by the lack of overlap in bacterial species. Routine hygienic maintenance of scrub sinks is recommended.

Czochralski crystal growth and characterization of large langatate (La3Ga5.5Ta0.5O14, LGT) crystals for SAW applications

1.5 and 2 inch LGT, langatate (La₃Ga_5.5Ta_0.5O₁₄) crystals along the X[100], Y[120] and Z[001]-directions were successfully grown by the Czochralski technique.