The accuracy of prehospital triage decisions in English trauma networks - a case-cohort study

BACKGROUND

Care for injured patients in England is provided by inclusive regional trauma networks. Ambulance services use triage tools to identify patients with major trauma who would benefit from expedited Major Trauma Centre (MTC) care. However, there has been no investigation of triage performance, despite its role in ensuring effective and efficient MTC care. This study aimed to investigate the accuracy of prehospital major trauma triage in representative English trauma networks.

METHODS

A diagnostic case-cohort study was performed between November 2019 and February 2020 in 4 English regional trauma networks as part of the Major Trauma Triage Study (MATTS). Consecutive patients with acute injury presenting to participating ambulance services were included, together with all reference standard positive cases, and matched to data from the English national major trauma database. The index test was prehospital provider triage decision making, with a positive result defined as patient transport with a pre-alert call to the MTC. The primary reference standard was a consensus definition of serious injury that would benefit from expedited major trauma centre care. Secondary analyses explored different reference standards and compared theoretical triage tool accuracy to real-life triage decisions.

RESULTS

The complete-case case-cohort sample consisted of 2,757 patients, including 959 primary reference standard positive patients. The prevalence of major trauma meeting the primary reference standard definition was 3.1% (n=54/1,722, 95% CI 2.3 - 4.0). Observed prehospital provider triage decisions demonstrated overall sensitivity of 46.7% (n=446/959, 95% CI 43.5-49.9) and specificity of 94.5% (n=1,703/1,798, 95% CI 93.4-95.6) for the primary reference standard. There was a clear trend of decreasing sensitivity and increasing specificity from younger to older age groups. Prehospital provider triage decisions commonly differed from the theoretical triage tool result, with ambulance service clinician judgement resulting in higher specificity.

CONCLUSIONS

Prehospital decision making for injured patients in English trauma networks demonstrated high specificity and low sensitivity, consistent with the targets for cost-effective triage defined in previous economic evaluations. Actual triage decisions differed from theoretical triage tool results, with a decreasing sensitivity and increasing specificity from younger to older ages.

Backed into a corner: damage control surgery in the rural or austere setting

Damage control surgery has evolved during the past 40 years. The initial cases and studies were performed at level 1 trauma centers but has now shifted to damage control at smaller hospitals. This buys time for definitive care at higher-level centers. There is a role for damage control surgery in both general surgery and trauma patients at community trauma centers. The successful implementation and completion of damage control surgery require thorough planning and a full understanding of resource limitation. Additional training or practice for infrequently performed procedures may be necessary. A systems-based approach with postoperative transfer to a higher level of care is acceptable and expected.

Haemodynamic response to pre-hospital emergency anaesthesia in trauma patients within an urban helicopter emergency medical service

PURPOSE

Pre-hospital emergency anaesthesia is routinely used in the care of severely injured patients by pre-hospital critical care services. Anaesthesia, intubation, and positive pressure ventilation may lead to haemodynamic instability. The aim of this study was to identify the frequency of new-onset haemodynamic instability after induction in trauma patients with a standardised drug regime.

METHODS

A retrospective database analysis was undertaken of all adult patients treated by a physician-led urban pre-hospital care service over a 6-year period. The primary outcome measure was the frequency of new haemodynamic instability following pre-hospital emergency anaesthesia. The association of patient characteristics and drug regimes with new haemodynamic instability was also analysed.

RESULTS

A total of 1624 patients were included. New haemodynamic instability occurred in 231 patients (17.4%). Patients where a full-dose regime was administered were less likely to experience new haemodynamic instability than those who received a modified dose regime (9.7% vs 24.8%, p < 0.001). The use of modified drug regimes became more common over the study period (p < 0.001) but there was no change in the rates of pre-existing (p = 0.22), peri-/post-anaesthetic (p = 0.36), or new haemodynamic instability (p = 0.32).

CONCLUSION

New haemodynamic instability within the first 30 min following pre-hospital emergency anaesthesia in trauma patients is common despite reduction of sedative drug doses to minimise their haemodynamic impact. It is important to identify non-drug factors that may improve cardiovascular stability in this group to optimise the care received by these patients.

Effects of empagliflozin on progression of chronic kidney disease: a prespecified secondary analysis from the empa-kidney trial

BACKGROUND

Sodium-glucose co-transporter-2 (SGLT2) inhibitors reduce progression of chronic kidney disease and the risk of cardiovascular morbidity and mortality in a wide range of patients. However, their effects on kidney disease progression in some patients with chronic kidney disease are unclear because few clinical kidney outcomes occurred among such patients in the completed trials. In particular, some guidelines stratify their level of recommendation about who should be treated with SGLT2 inhibitors based on diabetes status and albuminuria. We aimed to assess the effects of empagliflozin on progression of chronic kidney disease both overall and among specific types of participants in the EMPA-KIDNEY trial.

METHODS

EMPA-KIDNEY, a randomised, controlled, phase 3 trial, was conducted at 241 centres in eight countries (Canada, China, Germany, Italy, Japan, Malaysia, the UK, and the USA), and included individuals aged 18 years or older with an estimated glomerular filtration rate (eGFR) of 20 to less than 45 mL/min per 1·73 m2, or with an eGFR of 45 to less than 90 mL/min per 1·73 m2 with a urinary albumin-to-creatinine ratio (uACR) of 200 mg/g or higher. We explored the effects of 10 mg oral empagliflozin once daily versus placebo on the annualised rate of change in estimated glomerular filtration rate (eGFR slope), a tertiary outcome. We studied the acute slope (from randomisation to 2 months) and chronic slope (from 2 months onwards) separately, using shared parameter models to estimate the latter. Analyses were done in all randomly assigned participants by intention to treat. EMPA-KIDNEY is registered at ClinicalTrials.gov, NCT03594110.

FINDINGS

Between May 15, 2019, and April 16, 2021, 6609 participants were randomly assigned and then followed up for a median of 2·0 years (IQR 1·5-2·4). Prespecified subgroups of eGFR included 2282 (34·5%) participants with an eGFR of less than 30 mL/min per 1·73 m2, 2928 (44·3%) with an eGFR of 30 to less than 45 mL/min per 1·73 m2, and 1399 (21·2%) with an eGFR 45 mL/min per 1·73 m2 or higher. Prespecified subgroups of uACR included 1328 (20·1%) with a uACR of less than 30 mg/g, 1864 (28·2%) with a uACR of 30 to 300 mg/g, and 3417 (51·7%) with a uACR of more than 300 mg/g. Overall, allocation to empagliflozin caused an acute 2·12 mL/min per 1·73 m2 (95% CI 1·83-2·41) reduction in eGFR, equivalent to a 6% (5-6) dip in the first 2 months. After this, it halved the chronic slope from -2·75 to -1·37 mL/min per 1·73 m2 per year (relative difference 50%, 95% CI 42-58). The absolute and relative benefits of empagliflozin on the magnitude of the chronic slope varied significantly depending on diabetes status and baseline levels of eGFR and uACR. In particular, the absolute difference in chronic slopes was lower in patients with lower baseline uACR, but because this group progressed more slowly than those with higher uACR, this translated to a larger relative difference in chronic slopes in this group (86% [36-136] reduction in the chronic slope among those with baseline uACR <30 mg/g compared with a 29% [19-38] reduction for those with baseline uACR ≥2000 mg/g; ptrend<0·0001).

INTERPRETATION

Empagliflozin slowed the rate of progression of chronic kidney disease among all types of participant in the EMPA-KIDNEY trial, including those with little albuminuria. Albuminuria alone should not be used to determine whether to treat with an SGLT2 inhibitor.

FUNDING

Boehringer Ingelheim and Eli Lilly.

Impact of primary kidney disease on the effects of empagliflozin in patients with chronic kidney disease: secondary analyses of the EMPA-KIDNEY trial

BACKGROUND

The EMPA-KIDNEY trial showed that empagliflozin reduced the risk of the primary composite outcome of kidney disease progression or cardiovascular death in patients with chronic kidney disease mainly through slowing progression. We aimed to assess how effects of empagliflozin might differ by primary kidney disease across its broad population.

METHODS

EMPA-KIDNEY, a randomised, controlled, phase 3 trial, was conducted at 241 centres in eight countries (Canada, China, Germany, Italy, Japan, Malaysia, the UK, and the USA). Patients were eligible if their estimated glomerular filtration rate (eGFR) was 20 to less than 45 mL/min per 1·73 m2, or 45 to less than 90 mL/min per 1·73 m2 with a urinary albumin-to-creatinine ratio (uACR) of 200 mg/g or higher at screening. They were randomly assigned (1:1) to 10 mg oral empagliflozin once daily or matching placebo. Effects on kidney disease progression (defined as a sustained ≥40% eGFR decline from randomisation, end-stage kidney disease, a sustained eGFR below 10 mL/min per 1·73 m2, or death from kidney failure) were assessed using prespecified Cox models, and eGFR slope analyses used shared parameter models. Subgroup comparisons were performed by including relevant interaction terms in models. EMPA-KIDNEY is registered with ClinicalTrials.gov, NCT03594110.

FINDINGS

Between May 15, 2019, and April 16, 2021, 6609 participants were randomly assigned and followed up for a median of 2·0 years (IQR 1·5-2·4). Prespecified subgroupings by primary kidney disease included 2057 (31·1%) participants with diabetic kidney disease, 1669 (25·3%) with glomerular disease, 1445 (21·9%) with hypertensive or renovascular disease, and 1438 (21·8%) with other or unknown causes. Kidney disease progression occurred in 384 (11·6%) of 3304 patients in the empagliflozin group and 504 (15·2%) of 3305 patients in the placebo group (hazard ratio 0·71 [95% CI 0·62-0·81]), with no evidence that the relative effect size varied significantly by primary kidney disease (pheterogeneity=0·62). The between-group difference in chronic eGFR slopes (ie, from 2 months to final follow-up) was 1·37 mL/min per 1·73 m2 per year (95% CI 1·16-1·59), representing a 50% (42-58) reduction in the rate of chronic eGFR decline. This relative effect of empagliflozin on chronic eGFR slope was similar in analyses by different primary kidney diseases, including in explorations by type of glomerular disease and diabetes (p values for heterogeneity all >0·1).

INTERPRETATION

In a broad range of patients with chronic kidney disease at risk of progression, including a wide range of non-diabetic causes of chronic kidney disease, empagliflozin reduced risk of kidney disease progression. Relative effect sizes were broadly similar irrespective of the cause of primary kidney disease, suggesting that SGLT2 inhibitors should be part of a standard of care to minimise risk of kidney failure in chronic kidney disease.

FUNDING

Boehringer Ingelheim, Eli Lilly, and UK Medical Research Council.

Definitions matter: detection rates and perinatal outcome for infants classified prenatally as having late fetal growth restriction using SMFM biometric vs ISUOG/Delphi consensus criteria

OBJECTIVES

Fetal growth restriction (FGR) is often secondary to placental dysfunction and is suspected prenatally based on biometric or circulatory abnormalities detected on ultrasound. The aims of this study were to compare the screening performance of the Society for Maternal-Fetal Medicine (SMFM) biometric criteria (estimated fetal weight (EFW) or abdominal circumference (AC) < 10th centile) with that of the International Society of Ultrasound in Obstetrics and Gynecology (ISUOG)-endorsed Delphi consensus criteria for late FGR for delivery of a small-for-gestational-age (SGA) infant at term, emergency Cesarean section (CS) for non-reassuring fetal status (NRFS), perinatal mortality and composite severe neonatal morbidity.

METHODS

We classified retrospectively non-anomalous singleton infants as having late FGR (diagnosed ≥ 32 weeks) according to SMFM and ISUOG/Delphi criteria in a cohort of women who had been referred to the Mater Mother's Hospital, Brisbane, Australia and who delivered at term between January 2014 and December 2020. The study outcomes were delivery of a SGA infant (birth weight (BW) < 10th or < 3rd centile), emergency CS for NRFS, perinatal mortality (defined as stillbirth or neonatal death within 28 days of a live birth) and a composite of severe neonatal morbidity. We assessed the screening performance of various ultrasound variables by calculating the sensitivity, specificity, positive (PPV) and negative (NPV) predictive values, false-positive and false-negative rates, positive likelihood ratio (LR+) and negative likelihood ratio.

RESULTS

The SMFM and ISUOG/Delphi consensus criteria collectively classified 1030 cases as having late FGR. Of these, 400 cases were classified by both SMFM and ISUOG/Delphi criteria, whilst 548 cases were classified using only SMFM criteria and 82 cases were classified only by ISUOG/Delphi criteria. Prenatal detection of late FGR by SMFM and ISUOG/Delphi criteria was associated with increased odds of delivery of an infant with BW < 10th centile (SMFM: adjusted odds ratio (aOR), 133.0 (95% CI, 94.7-186.6); ISUOG/Delphi: aOR, 69.5 (95% CI, 49.1-98.2)) or BW < 3rd centile (SMFM: aOR, 348.7 (95% CI, 242.6-501.2); ISUOG/Delphi: aOR, 215.4 (95% CI, 148.4-312.7)). Compared with the SMFM criteria, the ISUOG/Delphi criteria were associated with lower odds (aOR, 0.5 (95% CI, 0.3-0.8)) of predicting a SGA infant with BW < 10th centile, but higher odds of predicting emergency CS for NRFS (aOR, 2.30 (95% CI, 1.14-4.66)) and composite neonatal morbidity (aOR, 1.22 (95% CI, 1.05-1.41)). Both SMFM and ISUOG/Delphi criteria were associated with high LR+, specificity, PPV and NPV for the prediction of infants with BW < 10th and BW < 3rd centile. However, both methods functioned much less efficiently for the prediction of composite severe neonatal morbidity or emergency CS for NRFS, with LR+ < 10. The SMFM biometric criteria alone, particularly AC < 3rd centile, had the highest LR+ values for the prediction of perinatal mortality.

CONCLUSION

Both the SMFM and ISUOG/Delphi criteria had strong screening potential for the detection of infants with BW < 10th or < 3rd centile but not for adverse neonatal outcome. © 2022 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

Nucleated red blood cells as a biomarker for mortality in infants and neonates requiring veno-arterial extracorporeal membrane oxygenation for cardiac disease

INTRODUCTION

Nucleated red blood cells (NRBC) are rare in the peripheral circulation of healthy individuals and their presence have been associated with mortality in adults and very low birth weight newborns, however, its value as a biomarker for mortality in infants requiring veno-arterial (VA) extracorporeal membrane oxygenation (ECMO) has yet to be studied. We sought to determine if NRBC can serve as a biomarker for ECMO mortality and inpatient mortality in infants requiring V-A ECMO.

METHODS

A single-center retrospective chart review analyzing infants <1 year of age requiring VA ECMO due to myocardial dysfunction or post-cardiotomy between January 1, 2011 to June 30, 2020.

RESULTS

One hundred two patients required VA ECMO. Sixty-five patients required ECMO post-cardiotomy, 19 for perioperative deterioration, and 18 for myocardial dysfunction. Fifty-one patients (50%) died (21 died on ECMO, 30 died post-ECMO decannulation). Multivariable analysis found Age <60 days (OR 13.0, 95% CI 1.9-89.6, p = 0.009), NRBC increase by >50% post-ECMO decannulation (OR 17.1, 95% CI 3.1-95.1, p = 0.001), Single Ventricle (OR 9.0, 95% CI 1.7-47.7, p = 0.01), and lactate at ECMO decannulation (OR 3.0, 95% CI 1.3-7.1, p = 0.011) to be independently associated with inpatient mortality. ROC curves evaluating NRBC pre-ECMO decannulation as a biomarker for mortality on ECMO (AUC 0.80, 95% CI 0.68-0.92, p ⩽ 0.001) and post-ECMO decannulation (AUC 0.75, 95% CI 0.65-0.84, p ⩽ 0.001) show NRBC to be an accurate biomarker for mortality.

CONCLUSIONS

Greater than 50% increase in NRBC post-ECMO decannulation is associated with inpatient mortality. NRBC value pre-ECMO decannulation may be a useful biomarker for mortality while on ECMO and post-decannulation.

Detecting Tweets Containing Cannabidiol-Related COVID-19 Misinformation Using Transformer Language Models and Warning Letters From Food and Drug Administration: Content Analysis and Identification

BACKGROUND

COVID-19 has introduced yet another opportunity to web-based sellers of loosely regulated substances, such as cannabidiol (CBD), to promote sales under false pretenses of curing the disease. Therefore, it has become necessary to innovate ways to identify such instances of misinformation.

OBJECTIVE

We sought to identify COVID-19 misinformation as it relates to the sales or promotion of CBD and used transformer-based language models to identify tweets semantically similar to quotes taken from known instances of misinformation. In this case, the known misinformation was the publicly available Warning Letters from Food and Drug Administration (FDA).

METHODS

We collected tweets using CBD- and COVID-19-related terms. Using a previously trained model, we extracted the tweets indicating commercialization and sales of CBD and annotated those containing COVID-19 misinformation according to the FDA definitions. We encoded the collection of tweets and misinformation quotes into sentence vectors and then calculated the cosine similarity between each quote and each tweet. This allowed us to establish a threshold to identify tweets that were making false claims regarding CBD and COVID-19 while minimizing the instances of false positives.

RESULTS

We demonstrated that by using quotes taken from Warning Letters issued by FDA to perpetrators of similar misinformation, we can identify semantically similar tweets that also contain misinformation. This was accomplished by identifying a cosine distance threshold between the sentence vectors of the Warning Letters and tweets.

CONCLUSIONS

This research shows that commercial CBD or COVID-19 misinformation can potentially be identified and curbed using transformer-based language models and known prior instances of misinformation. Our approach functions without the need for labeled data, potentially reducing the time at which misinformation can be identified. Our approach shows promise in that it is easily adapted to identify other forms of misinformation related to loosely regulated substances.

Cross-tissue, single-cell stromal atlas identifies shared pathological fibroblast phenotypes in four chronic inflammatory diseases

BACKGROUND

Pro-inflammatory fibroblasts are critical for pathogenesis in rheumatoid arthritis, inflammatory bowel disease, interstitial lung disease, and Sjögren's syndrome and represent a novel therapeutic target for chronic inflammatory disease. However, the heterogeneity of fibroblast phenotypes, exacerbated by the lack of a common cross-tissue taxonomy, has limited our understanding of which pathways are shared by multiple diseases.

METHODS

We profiled fibroblasts derived from inflamed and non-inflamed synovium, intestine, lungs, and salivary glands from affected individuals with single-cell RNA sequencing. We integrated all fibroblasts into a multi-tissue atlas to characterize shared and tissue-specific phenotypes.

FINDINGS

Two shared clusters, CXCL10+CCL19+ immune-interacting and SPARC+COL3A1+ vascular-interacting fibroblasts, were expanded in all inflamed tissues and mapped to dermal analogs in a public atopic dermatitis atlas. We confirmed these human pro-inflammatory fibroblasts in animal models of lung, joint, and intestinal inflammation.

CONCLUSIONS

This work represents a thorough investigation into fibroblasts across organ systems, individual donors, and disease states that reveals shared pathogenic activation states across four chronic inflammatory diseases.

FUNDING

Grant from F. Hoffmann-La Roche (Roche) AG.

Control of complex behavior by astrocytes and microglia

Evidence that glial cells influence behavior has been gaining a steady foothold in scientific literature. Out of the five main subtypes of glial cells in the brain, astrocytes and microglia have received an outsized share of attention with regard to shaping a wide spectrum of behavioral phenomena and there is growing appreciation that the signals intrinsic to these cells as well as their interactions with surrounding neurons reflect behavioral history in a brain region-specific manner. Considerable regional diversity of glial cell phenotypes is beginning to be recognized and may contribute to behavioral outcomes arising from circuit-specific computations within and across discrete brain nuclei. Here, we summarize current knowledge on the impact of astrocyte and microglia activity on behavioral outcomes, with a specific focus on brain areas relevant to higher cognitive control, reward-seeking, and circadian regulation.

Mechanisms associated with the rapid decline in sea ice cover around a stranded ship in the Lazarev Sea, Antarctica

In the satellite data era starting from 1979, the extent of Antarctic sea ice increased moderately for the first 37 years. However, the extent decreased to record low levels from 2016 to 2020, with the drop being greatest in the Weddell and Lazarev Seas of the Southern Ocean. An important question for the scientific fraternity and policymakers is to understand what ocean-atmospheric processes triggered such a rapid decline in sea ice. We employ in-situ, satellite, and atmospheric reanalysis data to examine the causative mechanism of anomalous sea ice variability in the Lazarev Sea at a time of ice growth in the annual cycle (March-April 2019), when a cargo ship was stuck in extensive ice cover and freed following the unusual decline in sea ice. High-resolution Sentinel-1 synthetic aperture radar captured a distinct view of the ship location and track within extensive ice cover of fast sea ice, dense pack ice, and icebergs in the Lazarev Sea on 27 March 2019. Subsequently, the sea ice cover declined and reached the fourth lowest extent in the entire satellite record during April 2019 which was 25.6% lower than the long-term mean value of 2.65 × 10⁶ km². We show that the anomalous sea ice variability was due to the occurrence of eastward-moving polar cyclones, including a quasi-stationary explosive development that impacted sea ice through extreme changes in ocean-atmospheric conditions. The cyclone-induced dynamic (poleward propagation of ocean waves and ice motion) and thermodynamic (heat and moisture plumes from midlatitudes, ocean mixed layer warming) processes coupled with high tides provided a conducive environment for an exceptional decline in sea ice over the region of ship movement.

A193 PERCEIVED BARRIERS TO GLUTEN-FREE FOOD ACCESS ON-CAMPUS EXPERIENCED BY STUDENTS FROM DIFFERENT CANADIAN UNIVERSITIES AND COLLEGES

Background

Students with gluten-related disorders (GRD), a spectrum of conditions including celiac disease (CeD) and non-celiac wheat sensitivity (NCWS), often experience challenges when accessing gluten-free (GF) foods.

Aims

To identify barriers perceived by students with GRD to access GF products on-campus of universities and colleges across Canada.

Methods

We conducted a cross sectional survey using the RedCap platform and distributed it to the Canadian Celiac Association community. We included students who reported adopting a GFD for various reasons including CeD and other GRD. We collected data on adherence to the GFD using a validated questionnaire (CDAT), presence of perceived barriers to follow a GFD while dining on campus, persistent symptoms, and altered quality of life. Continuous data are expressed as median (IQR), and categorical data as proportions of patients. Mann-Whitney U and Chi2 with Fisher correction were used to assess differences between groups.

Results

Seventy nine students responded to the survey (5% male and median age = 25 yrs) and 78 had complete data for analysis. Of the 78 students, 52 (66.6%) reported a diagnosis of CeD, while 26 were adopting a GFD for other reasons (non-CeD). The majority were enrolled in university programs (72/78) and 18% were living on-campus. Almost 90% reported difficulties maintaining a GFD while dining on-campus. Similar proportion of CeD and non-CeD reported eating gluten accidentally (75% vs 80%), while 15% reported eating gluten intentionally on-campus at least a few times per week. This was observed more frequently in non-CeD compared with students with CeD (61% vs 17%; p=0.04). Barriers identified in CeD versus non-CeD groups were related to a reduced GF-food variety (48% vs 69%), lack of availability of GF food (21% vs 46%) and increased cost (46% vs 81%) compared with gluten-containing counterparts. The majority of participants were concerned whether the food available on-campus was truly GF (80% vs 54%) as they reported foods not properly labelled. The majority of participants considered their overall health (79%) and quality of life (65%) was fair to terrible while dining on campus. During the pandemic, 76% of them perceived that it was easier to stick to a GF diet.

Conclusions

Students from various universities and colleges across Canada experience barriers to access GF food on-campus. This has a significant impact on their overall health and quality of life. Proper food labeling, GF certification and improving the variety of GF food on-campus are options for improvement.

Funding Agencies

None

Infodemiological Examination of Personal and Commercial Tweets About Cannabidiol: Term and Sentiment Analysis

BACKGROUND

In the absence of official clinical trial information, data from social networks can be used by public health and medical researchers to assess public claims about loosely regulated substances such as cannabidiol (CBD). For example, this can be achieved by comparing the medical conditions targeted by those selling CBD against the medical conditions patients commonly treat with CBD.

OBJECTIVE

The objective of this study was to provide a framework for public health and medical researchers to use for identifying and analyzing the consumption and marketing of unregulated substances. Specifically, we examined CBD, which is a substance that is often presented to the public as medication despite complete evidence of efficacy and safety.

METHODS

We collected 567,850 tweets by searching Twitter with the Tweepy Python package using the terms "CBD" and "cannabidiol." We trained two binary text classifiers to create two corpora of 167,755 personal use and 143,322 commercial/sales tweets. Using medical, standard, and slang dictionaries, we identified and compared the most frequently occurring medical conditions, symptoms, side effects, body parts, and other substances referenced in both corpora. In addition, to assess popular claims about the efficacy of CBD as a medical treatment circulating on Twitter, we performed sentiment analysis via the VADER (Valence Aware Dictionary for Sentiment Reasoning) model on the personal CBD tweets.

RESULTS

We found references to medically relevant terms that were unique to either personal or commercial CBD tweet classes, as well as medically relevant terms that were common to both classes. When we calculated the average sentiment scores for both personal and commercial CBD tweets referencing at least one of 17 medical conditions/symptoms terms, an overall positive sentiment was observed in both personal and commercial CBD tweets. We observed instances of negative sentiment conveyed in personal CBD tweets referencing autism, whereas CBD was also marketed multiple times as a treatment for autism within commercial tweets.

CONCLUSIONS

Our proposed framework provides a tool for public health and medical researchers to analyze the consumption and marketing of unregulated substances on social networks. Our analysis showed that most users of CBD are satisfied with it in regard to the condition that it is being advertised for, with the exception of autism.

Massive hemoperitoneum without peritoneal signs: An unusual presentation of omental ectopic rupture. A case report

Background

Extrauterine ectopic pregnancy is a rare form of ectopic pregnancy, accounting for roughly 1:10,000–30,000 of all pregnancies. Primary omental pregnancy is the least common form of abdominal ectopic pregnancies, making it extremely rare. Typical presentation includes pelvic pain, secondary amenorrhea, with or without vaginal bleeding. Atypical presentations range from nonspecific pain to asymptomatic.

Case

A 19-year-old woman presented to the emergency department after several syncopal episodes. She had a positive urine pregnancy test (serum hCG 446 IU/L). Her hemoglobin level was 10.6 g/dL. Due to lack of pain or bleeding, abdominal imaging was not indicated. A head CT scan rendered negative results. She was subsequently diagnosed with idiopathic headaches and anemia and was discharged. She returned to hospital 48 h later with vaginal bleeding and additional syncopal episodes. She was not experiencing any abdominal pain or discomfort. Her anemia worsened (hemoglobin 7.5 g/dL). For this reason, imaging was performed. It was significant for massive hemoperitoneum. Due to the imaging findings and worsening anemia, diagnostic exploratory laparoscopy was recommended to evaluate for ruptured ectopic pregnancy. Laparoscopic findings revealed large hemoperitoneum and a 10-week gestational sac attached to the greater omentum near the transverse colon. This exceedingly rare presentation of extrauterine ectopic pregnancy offered few clinical clues other than worsening anemia until imaging later revealed the abnormality. Ruptured ectopic pregnancy, a potentially fatal complication of pregnancy, should be included into the differential diagnosis of any gravid patient with syncope and anemia unexplained by extensive diagnostic workup.

•

Primary omental ectopic pregnancy is exceedingly rare.

•

Ectopic pregnancy with massive hemoperitoneum can present as painless, occult bleeding.

•

Hemodynamic instability is often overlooked in early pregnancy due to expectation of low blood pressure.

The complement system drives local inflammatory tissue priming by metabolic reprogramming of synovial fibroblasts

Arthritis typically involves recurrence and progressive worsening at specific predilection sites, but the checkpoints between remission and persistence remain unknown. Here, we defined the molecular and cellular mechanisms of this inflammation-mediated tissue priming. Re-exposure to inflammatory stimuli caused aggravated arthritis in rodent models. Tissue priming developed locally and independently of adaptive immunity. Repeatedly stimulated primed synovial fibroblasts (SFs) exhibited enhanced metabolic activity inducing functional changes with intensified migration, invasiveness and osteoclastogenesis. Meanwhile, human SF from patients with established arthritis displayed a similar primed phenotype. Transcriptomic and epigenomic analyses as well as genetic and pharmacological targeting demonstrated that inflammatory tissue priming relies on intracellular complement C3- and C3a receptor-activation and downstream mammalian target of rapamycin- and hypoxia-inducible factor 1α-mediated metabolic SF invigoration that prevents activation-induced senescence, enhances NLRP3 inflammasome activity, and in consequence sensitizes tissue for inflammation. Our study suggests possibilities for therapeutic intervention abrogating tissue priming without immunosuppression.

37 Improving the Management of Post-Operative Hypocalcaemia in Thyroid Surgery

Introduction

Hypocalcaemia is a frequent, and potentially dangerous, complication of total thyroidectomy [1, 2]. This quality improvement (QI) project was undertaken in a large ENT department in the East of England over a year. The project improved postoperative guideline compliance by optimising the recognition and management of patients at risk of hypocalcaemia. This process focussed on improving parathyroid hormone (PTH) and calcium blood testing, appropriate prescribing and the monitoring and management of hypocalcaemia.

Method

Following a baseline audit the QI process subsequently involved the introduction of a new intraoperative PTH pathway and the amendment of trust guidelines. In addition, there was a focus on improving clinician awareness of guidelines, junior doctor education, communication between operating surgeons and junior doctors and the optimisation of patient handover.

Results

The measurement of PTH at four hours improved from 42.5% to 52.2%. The project saw a significant improvement in the monitoring of hypocalcaemia (from 22.2% to 83.3% for patients with an intermediate risk of hypocalcaemia) and in the prescribing of prophylactic calcium supplements from 7.5% to 43.5%.

Conclusions

By optimising postoperative care this QI project improved patient safety as well as impacting on the duration, and overall cost, of inpatient stay.

Gallstone Ileus Treated by Incidental Meckel's Diverticulectomy

Gallstone ileus is an uncommon cause of intestinal obstruction in the elderly. It is typically recognized on computed tomography by the presence of pneumobilia and a gallstone in the right iliac fossa. Nonetheless, it is important to consider that gallstone ileus may represent the presentation of another pathology rather than an entity on its own. Here, we report successful retrieval of a gallstone that was causing ileus. Intraoperatively, the gallstone was noted lodged in the terminal ileum distal to an incidentally noted Meckel’s diverticulum. The gallstone was milked proximally into the Meckel’s diverticulum and the base was transected. This case illustrates a rare, but unique, surgical technique utilizing a small bowel diverticulum as a vector for stone removal.

A33 MEALTIME SUPPORT: A PILOT COHORT STUDY OF AN EFFECTIVE, COST-SAVING OUTPATIENT HUNGER-BASED FEEDING PROGRAM FOR TUBE DEPENDENCY

Background

Tube dependency is an under recognized complication of long-term enteral feeding in young children. Many children struggle to progress to full oral feeds even with sufficient oral motor skills and swallowing ability. Tube dependency greatly impacts the quality of life of children and families and is a significant burden to the health care system. Economic challenges, increased burden of care and psychosocial issues all reinforce the need for timely tube removal.

Aims

We aimed to examine the efficacy of a multidisciplinary child-led, hunger-based approach called “Mealtime Support” at the Stollery Children’s Hospital in Edmonton. Nutritional outcomes, parental satisfaction and cost implications were evaluated. As a secondary aim we sought to determine the rates of gastrostomy tube insertions in the pediatric age range across Canada as a potential indicator of increasing need for long term tube feeding, hence the need for cost effective tube weaning programs to be developed in Canada.

Methods

The ambulatory program was delivered 2–3 times a day, for 2 weeks, by an occupational therapist and dietitian, under medical supervision. Hunger was promoted by reducing tube fed calories by 80% prior to commencement. Top-up tube feeds were given immediately after feeding sessions if needed. Caregivers completed 12-question subjective surveys pre and post intervention. Micro-costing methods compared costs between the program and ongoing tube feeding. The number of pediatric hospital admissions and gastrostomy tube insertions from 2008–2019, per province, was collected from the Canadian Institute for Health Information (CIHI).

Results

From 2016 - 2017, 6 children who had been tube fed from 7 to 21 months in total were enrolled and 5 completed the program. At 1-month post intervention, 4/5 of the children were 100% orally fed. Parents reported improvement in mealtime struggles (p-value = 0.005), reduction in worry about their child’s eating (p-value = 0.005) and improvement in their child’s appetite/variety foods eaten (p-value = 0.004). Over a year the potential cost savings were estimated at $42,471.24. By 6-months, all feeding tubes were removed. Based on the CIHI data, the number of gastrostomy tubes inserted per 100,000 children varied significantly between provinces, but highest in Nova Scotia, Saskatchewan and Alberta with increases seen from 2008–2018.

Conclusions

The transition from tube feeding to oral feeding is difficult for children who are tube dependent and poses several economic and psychosocial challenges. Mealtime Support was safe and successful in reducing tube dependency and cost-effective compared to no intervention or hospital based programs. There is a need to develop and fund Canadian outpatient feeding programs.

Funding Agencies

The Stollery Children’s Foundation

Penetrating Thoracoabdominal Trauma With a Cryptic Diaphragmatic Injury in a 23-Year-Old Male

Traumatic diaphragmatic injuries are a rare entity and can occur in relation to penetrating thoracic and abdominal trauma. The most common clinical features of diaphragm rupture include chest or abdominal bruising, decreased breath sounds, and signs of bowel obstruction. However, the classic signs and symptoms of diaphragmatic injury are not always present and can be obscured even in the highest resolution imaging. This highlights the importance for maintaining a high index of suspicion to make the diagnosis and properly manage these patients. Here, we present a rare case of a 23-year-old male who experienced a laceration to his left thorax and was later discovered to have concurrent diaphragmatic injury despite an initially noncontributory physical exam and imaging findings. The patient subsequently underwent robotic repair of the injury and reduction of herniated contents.

Outcomes following emergency colorectal cancer presentation in the elderly

AIM

Colorectal cancer is predominantly a disease of the elderly and up to 30% of these patients will present as an emergency. We compared the outcomes of 'elderly' patients presenting to our unit with a colorectal cancer emergency over a 10-year period with those of a 'younger' cohort.

METHODS

A single centre retrospective review of colorectal cancer emergencies between 1 April 2007 and 1 April 2017 was performed. Patients were separated into two cohorts: 'young' (< 75 years) and 'elderly' (≥ 75 years). Data collected included demographics, disease status, treatment and outcomes.

RESULTS

A total of 341 patients (< 75 years: n = 154; ≥ 75 years: n = 187) presented as a colorectal cancer emergency. Significantly fewer 'elderly' patients underwent curative surgical procedures (72% vs 49%, P < 0.0001) or received adjuvant chemotherapy (56% vs 21%, P < 0.0001). 'Elderly' patients had significantly more postoperative cardio-respiratory complications (7% vs 36%, P < 0.0001), but despite this there was no significant difference in 30-day mortality (7% vs 12%) and survival rates at 1 year (75% vs 74%) or 3 years (56% vs 49%). Elderly patients treated with best supportive care had a median overall survival of just 62 (range 1-955) days.

CONCLUSION

Patients ≥ 75 years presenting as a colorectal cancer emergency were significantly less likely to undergo emergency curative surgery or receive adjuvant chemotherapy than those < 75 years. However, the 30-day mortality, 1- and 3-year survival rates for patients undergoing curative surgery were comparable.

Creation of skyrmions in van der Waals ferromagnet Fe3GeTe2 on (Co/Pd) n superlattice

Magnetic skyrmions are topological spin textures, which usually exist in noncentrosymmetric materials where the crystal inversion symmetry breaking generates the so-called Dzyaloshinskii-Moriya interaction. This requirement unfortunately excludes many important magnetic material classes, including the recently found two-dimensional van der Waals (vdW) magnetic materials, which offer unprecedented opportunities for spintronic technology. Using photoemission electron microscopy and Lorentz transmission electron microscopy, we investigated and stabilized Néel-type magnetic skyrmion in vdW ferromagnetic Fe₃GeTe₂ on top of (Co/Pd) _n in which the Fe₃GeTe₂ has a centrosymmetric crystal structure. We demonstrate that the magnetic coupling between the Fe₃GeTe₂ and the (Co/Pd) _n could create skyrmions in Fe₃GeTe₂ without the need of an external magnetic field. Our results open exciting opportunities in spintronic research and the engineering of topologically protected nanoscale features by expanding the group of skyrmion host materials to include these previously unknown vdW magnets.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

A113 COST SAVINGS OF SEROLOGIC VERSUS BIOPSY PROVEN DIAGNOSIS OF PEDIATRIC CELIAC DISEASE

Background

Celiac disease (CD) affects approximately one percent of the population in Canada and the United States. At present, endoscopic diagnosis (ED) of CD remains the gold standard in North America, despite mounting evidence and validated European guidelines for serologic diagnosis (SD). Within publicly funded healthcare systems there is pressure to ensure optimal resource utilization and cost efficiency, including for endoscopic services. At Stollery Children’s Hospital, Edmonton, Canada, we have adopted serologic diagnosis as routine practice since 2016.

Aims

The aim of this study is to estimate cost savings, i.e. hard dollar savings and capacity improvements, to the health care system as well as impacts on families in regard to reduced work days lost and missing child school days for SD versus ED. Initial cost saving data is presented.

Methods

Micro-costing methods were used to determine health care resource use in patients undergoing ED or SD from 2017–2018. SD testing included anti-tissue glutaminase antibody (aTTG) ≥200IU/mL (on two occasions), human leukocyte antigen (HLA) DQA5/DQ2, blood sampling, transport and laboratory costs. ED diagnosis included gastroenterologist, anesthetist, OR equipment, staff, overhead and histopathology. Cost of each unit of resource was obtained from the schedule of medical benefits (Alberta) and reported average ambulatory cost for day hospital endoscopy for Stollery Children’s Hospital determined in 2016; reported in CAN$.

Results

Between March 2017-December 2018, 473 patients were referred for diagnosis of CD; 233 had ED and 127 SD. Estimated cost for ED was $1240 per patient; for SD was $85 per patient (6.8% of ED cost). Based on 127 patients not requiring endoscopy and a cost saving of $1155 per patient there was a total cost savings of $146,685 over 22 months.

Conclusions

A SD approach presents a significant cost savings to the public health care system. It also frees up valuable endoscopic resources, and limits exposure of children to the immediate and long-term risks associated with anesthesia and biopsy. SD also decreases time to diagnosis and the cost of the process to families (lost days of school/work, travel costs etc.). Our costing data can be used in combination with mounting evidence on the test performance of SD versus ED to determine cost-effectiveness of serological diagnosis for pediatric CD. Given the potential for cost saving and more efficient operating room utilization, SD for pediatric CD warrants further investigation in North America.

Funding Agencies

None

A134 RATES OF PARENTERAL NUTRITION-ASSOCIATED CHOLESTASIS/LIVER DISEASE AND GROWTH PRE- AND POST-SMOFLIPID INTRODUCTION IN NEONATES AND INFANTS WITH INTESTINAL FAILURE

Background

Parenteral nutrition (PN) is essential for survival in infants with intestinal failure (IF). PN-associated cholestasis (PNAC) and liver disease (PNALD) are life-threatening complications of long-term PN use. SMOFlipid (soybean oil, medium-chain triglycerides, olive oil, and fish oil) has recently been approved as an off-label alternative to the conventional soy-based lipid emulsion (Intralipid). It is thought to have anti-cholestatic properties due to its more diverse lipid composition. Due to its’ recent approval in Canada (2013) and the USA (2016), data remains sparse.

Aims

We aim to determine if infants with IF receiving SMOFlipid had significantly lower rates of PNAC and improved growth compared to those receiving Intralipid.

Methods

All patients (≤1 year old at start of PN therapy) who received PN of any duration at two tertiary pediatric hospitals in Edmonton (2010–2018) were identified from the shared pharmacy database. Those with IF who received one type of PN continuously for ≥6 weeks total were included. Individuals with an initial serum conjugated bilirubin &gt;50 µmol/L and/or who had PN interruptions &gt;5 days were excluded. Data on liver parameters, growth, and complications were collected. Non-parametric tests (Mann-Whitney U test for continuous variables and χ2 test for categorical variables) were used to compare PNAC/PNALD (serum conjugated bilirubin &gt;34umol/L during PN) and growth (weight/length/head circumference z-scores) between SMOFlipid and Intralipid.

Results

1777 patients were reviewed; 40 infants (55% male), median age 4 weeks (range 0–48 weeks) at the time of PN initiation, met the inclusion criteria. Reasons for exclusion (n=1737) were receiving PN &lt;6 weeks total (n=1485), duplicate patients (n=154), receiving multiple types of PN with each less than 6 weeks total (n=62), an initial serum conjugated bilirubin &gt;50umol/L (n=21), more than 5 consecutive days off of PN (n=12), and older than 1 year old at time of PN initiation (n=3). Twenty-one patients (53%) received SMOFlipid, 15 (38%) Intralipid, and 4 (10%) Omegaven for ≥6 weeks. The majority (92%) were in an intensive care unit (neonatal or pediatric). No patients were septic when starting PN. Individuals received PN over a median of 7.9 weeks (range 6–27 weeks).

Conclusions

As expected, neonatal onset intestinal failure is rare in Edmonton. In our tertiary pediatric institutions, 2010–2018, SMOFLipid was the predominant lipid choice for infants with intestinal failure, followed by Intralipid. Omegaven was used rarely. This dataset will now allow us to compare the rates of PNAC at six weeks post-PN initiation and differences in growth between infants with IF receiving SMOFlipid versus the traditional Intralipid in our Canadian setting. Analysis is currently underway.

Funding Agencies

Women and Children’s Health Research Institute (WCHRI) at the University of Alberta

7 Stop Falling Before it Starts: Increasing Access to Multifactorial Falls and Fracture Risk Assessment and Intervention for Older People At Risk of Falls or Early in Their Falls Career Via Proactive Case Finding

Background

Target population: patients from 6 (of 43) Newcastle upon Tyne General Practices, age 65 – 75, mild frailty on electronic frailty index, who had fallen or noticed a balance problem in the previous year.

Introduction

Usually multifactorial falls and fracture prevention services target frailer older people and intervention begins after a fall or fracture has occurred. There is limited provision of community-based strength and balance exercise.

Intervention

New service model ‘Stop Falling Before It Starts (SFBIS)’: proactive case finding by postal questionnaire; multifactorial falls and fracture risk assessment by specialist nurse; interventions recommended to General Practitioner (GP); community-based exercise offered to all, predominantly new 15 week ‘Steady On’ strength and balance classes suitable for fitter older people.

Methods

Data collection: patient characteristics, physical performance (Timed up and Go (TUG), 30 second sit to stand (STS)) before starting and on completion of Steady On classes, service process measures, patient and GP experience.

Results

157 patients assessed. 80 (51%) fallen in previous year. 9 (6%) history of syncope / pre-syncope. 18 (11%) orthostatic hypotension. 124 (79%) culprit medications. Recommendations: GP review of history 6 (4%) or medications 13 (8%); referral to secondary care falls service 1 (0.5%); optician assessment 58 (37%); DXA 13 (8%). 131 (83%) referred to Steady On; 119 (91%) attended first class, 61 (51%) completed classes. Mean initial TUG 11 seconds, mean improvement 3 seconds. Mean initial STS 11 repetitions, mean improvement 3 repetitions. Mean patient feedback score 14.6/15 (15 best). GP feedback positive.

Conclusions

SFBIS was effective in identifying the target population and engaging them in community-based strength and balance exercise classes. Meaningful improvements in physical performance were demonstrated. A smaller number of additional risk factors were identified. There was a high level of satisfaction from patients and GPs. Wider implementation would increase participation in evidence-based community exercise.

Determinants of diagnostic discordance for non-diabetic hyperglycaemia and Type 2 diabetes using paired glycated haemoglobin measurements in a large English primary care population: cross-sectional study

AIM

To investigate factors influencing diagnostic discordance for non-diabetic hyperglycaemia and Type 2 diabetes.

METHODS

Some 10 000 adults at increased risk of diabetes were screened with HbA_1c and fasting plasma glucose (FPG). The 2208 participants with initial HbA_1c ≥ 42 mmol/mol (≥ 6.0%) or FPG ≥ 6.1 mmol/l were retested after a median 40 days. We compared the first and second HbA_1c results, and consequent diagnoses of non-diabetic hyperglycaemia and Type 2 diabetes, and investigated predictors of discordant diagnoses.

RESULTS

Of 1463 participants with non-diabetic hyperglycaemia and 394 with Type 2 diabetes on first testing, 28.4% and 21.1% respectively had discordant diagnoses on repeated testing. Initial diagnosis of non-diabetic hyperglycaemia and/or impaired fasting glucose according to both HbA_1c and FPG criteria, or to FPG only, made reclassification as Type 2 diabetes more likely than initial classification according to HbA_1c alone. Initial diagnosis of Type 2 diabetes according to both HbA_1c and FPG criteria made reclassification much less likely than initial classification according to HbA_1c alone. Age, and anthropometric and biological measurements independently but inconsistently predicted discordant diagnoses and changes in HbA_1c .

CONCLUSIONS

Diagnosis of non-diabetic hyperglycaemia or Type 2 diabetes with a single measurement of HbA_1c in a screening programme for entry to diabetes prevention trials is unreliable. Diagnosis of non-diabetic hyperglycaemia and Type 2 diabetes should be confirmed by repeat testing. FPG results could help prioritise retesting. These findings do not apply to people classified as normal on a single test, who were not retested.

Psychological intervention (ConquerFear) for treating fear of cancer recurrence: mediators and moderators of treatment efficacy

PURPOSE

ConquerFear is an efficacious intervention for fear of cancer recurrence (FCR) that demonstrated greater improvements than an attention control (relaxation training) in a randomized controlled trial. This study aimed to determine mediators and moderators of the relative treatment efficacy of ConquerFear versus relaxation.

METHODS

One hundred and fifty-two cancer survivors completed 5 therapy sessions and outcome measures before and after intervention and at 6 months' follow-up. We examined theoretically relevant variables as potential mediators and moderators of treatment outcome. We hypothesized that metacognitions and intrusions would moderate and mediate the relationship between treatment group and FCR level at follow-up.

RESULTS

Only total FCR score at baseline moderated treatment outcome. Participants with higher levels of FCR benefited more from ConquerFear relative to relaxation on the primary outcome. Changes in metacognitions and intrusive thoughts about cancer during treatment partially mediated the relationship between treatment group and FCR.

CONCLUSIONS

These results show that ConquerFear is relatively more effective than relaxation for those with overall higher levels of FCR. The mediation analyses confirmed that the most likely mechanism of treatment efficacy was the reduction in unhelpful metacognitions and intrusive thoughts during treatment, consistent with the theoretical framework underpinning ConquerFear.

IMPLICATIONS FOR CANCER SURVIVORS

ConquerFear is a brief, effective treatment for FCR in cancer survivors with early-stage disease. The treatment works by reducing intrusive thoughts about cancer and changing beliefs about worry and is particularly helpful for people with moderate to severe FCR.

Immunofibroblasts are pivotal drivers of tertiary lymphoid structure formation and local pathology

Resident fibroblasts at sites of infection, chronic inflammation, or cancer undergo phenotypic and functional changes to support leukocyte migration and, in some cases, aggregation into tertiary lymphoid structures (TLS). The molecular programming that shapes these changes and the functional requirements of this population in TLS development are unclear. Here, we demonstrate that external triggers at mucosal sites are able to induce the progressive differentiation of a population of podoplanin (pdpn)-positive stromal cells into a network of immunofibroblasts that are able to support the earliest phases of TLS establishment. This program of events, that precedes lymphocyte infiltration in the tissue, is mediated by paracrine and autocrine signals mainly regulated by IL13. This initial fibroblast network is expanded and stabilized, once lymphocytes are recruited, by the local production of the cytokines IL22 and lymphotoxin. Interfering with this regulated program of events or depleting the immunofibroblasts in vivo results in abrogation of local pathology, demonstrating the functional role of immunofibroblasts in supporting TLS maintenance in the tissue and suggesting novel therapeutic targets in TLS-associated diseases.

Deliberating performance targets workshop: Potential paths for emerging PM2.5 and O3 air sensor progress

The United States Environmental Protection Agency held an international two-day workshop in June 2018 to deliberate possible performance targets for non-regulatory fine particulate matter (PM_2.5) and ozone (O₃) air sensors. The need for a workshop arose from the lack of any market-wide manufacturer requirement for Ozone documented sensor performance evaluations, the lack of any independent third party or government-based sensor performance certification program, and uncertainty among all users as to the general usability of air sensor data. A multi-sector subject matter expert panel was assembled to facilitate an open discussion on these issues with multiple stakeholders. This summary provides an overview of the workshop purpose, key findings from the deliberations, and considerations for future actions specific to sensors. Important findings concerning PM_2.5 and O₃ sensors included the lack of consistent performance indicators and statistical metrics as well as highly variable data quality requirements depending on the intended use. While the workshop did not attempt to yield consensus on any topic, a key message was that a number of possible future actions would be beneficial to all stakeholders regarding sensor technologies. These included documentation of best practices, sharing quality assurance results along with sensor data, and the development of a common performance target lexicon, performance targets, and test protocols.

Health concerns of cancer survivors after primary anti-cancer treatment

PURPOSE

Cancer survivors experience significant health concerns compared to the general population. Sydney Survivorship Clinic (SSC) is a multi-disciplinary clinic aiming to help survivors treated with curative intent manage side effects, and establish a healthy lifestyle. Here, we determine the health concerns of survivors post-primary treatment.

METHODS

Survivors completed questionnaires assessing symptoms, quality of life (QOL), distress, diet, and exercise before attending SSC, and a satisfaction survey after. Body mass index (BMI), clinical findings and recommendations were reviewed. Descriptive statistical methods were used.

RESULTS

Overall, 410 new patients attended SSC between September 2013 and April 2018, with 385 survivors included in analysis: median age 57 years (range 18-86); 69% female; 43% breast, 31% colorectal and 19% haematological cancers. Median time from diagnosis, 12 months. Common symptoms of at least moderate severity: fatigue (45%), insomnia (37%), pain (34%), anxiety (31%) and with 56% having > 5 moderate-severe symptoms. Overall, 45% scored distress ≥ 4/10 and 62% were rated by clinical psychologist as having 'fear of cancer recurrence'. Compared to population mean of 50, mean global QOL T-score was 47.2, with physical and emotional well-being domains most affected. Average BMI was 28.2 kg/m² (range 17.0-59.1); 61% overweight/obese. Only 31% met aerobic exercise guidelines. Overall, 98% 'agreed'/'completely agreed' attending the SSC was worthwhile, and 99% would recommend it to others.

CONCLUSION

Distress, fear of cancer recurrence, fatigue, obesity and sedentary lifestyle are common in cancer survivors attending SSC and may best be addressed in a multi-disciplinary Survivorship Clinic to minimise longer-term effects. This model is well-rated by survivors.

The effect of temperature, farm density and foot-and-mouth disease restrictions on the 2007 UK bluetongue outbreak

In 2006, bluetongue (BT), a disease of ruminants, was introduced into northern Europe for the first time and more than two thousand farms across five countries were affected. In 2007, BT affected more than 35,000 farms in France and Germany alone. By contrast, the UK outbreak beginning in 2007 was relatively small, with only 135 farms in southeast England affected. We use a model to investigate the effects of three factors on the scale of BT outbreaks in the UK: (1) place of introduction; (2) temperature; and (3) animal movement restrictions. Our results suggest that the UK outbreak could have been much larger had the infection been introduced into the west of England either directly or as a result of the movement of infected animals from southeast England before the first case was detected. The fact that air temperatures in the UK in 2007 were marginally lower than average probably contributed to the UK outbreak being relatively small. Finally, our results indicate that BT movement restrictions are effective at controlling the spread of infection. However, foot-and-mouth disease restrictions in place before the detection and control of BT in 2007 almost certainly helped to limit BT spread prior to its detection.

Critical care usage after major gastrointestinal and liver surgery: a prospective, multicentre observational study

BACKGROUND

Patient selection for critical care admission must balance patient safety with optimal resource allocation. This study aimed to determine the relationship between critical care admission, and postoperative mortality after abdominal surgery.

METHODS

This prespecified secondary analysis of a multicentre, prospective, observational study included consecutive patients enrolled in the DISCOVER study from UK and Republic of Ireland undergoing major gastrointestinal and liver surgery between October and December 2014. The primary outcome was 30-day mortality. Multivariate logistic regression was used to explore associations between critical care admission (planned and unplanned) and mortality, and inter-centre variation in critical care admission after emergency laparotomy.

RESULTS

Of 4529 patients included, 37.8% (n=1713) underwent planned critical care admissions from theatre. Some 3.1% (n=86/2816) admitted to ward-level care subsequently underwent unplanned critical care admission. Overall 30-day mortality was 2.9% (n=133/4519), and the risk-adjusted association between 30-day mortality and critical care admission was higher in unplanned [odds ratio (OR): 8.65, 95% confidence interval (CI): 3.51-19.97) than planned admissions (OR: 2.32, 95% CI: 1.43-3.85). Some 26.7% of patients (n=1210/4529) underwent emergency laparotomies. After adjustment, 49.3% (95% CI: 46.8-51.9%, P<0.001) were predicted to have planned critical care admissions, with 7% (n=10/145) of centres outside the 95% CI.

CONCLUSIONS

After risk adjustment, no 30-day survival benefit was identified for either planned or unplanned postoperative admissions to critical care within this cohort. This likely represents appropriate admission of the highest-risk patients. Planned admissions in selected, intermediate-risk patients may present a strategy to mitigate the risk of unplanned admission. Substantial inter-centre variation exists in planned critical care admissions after emergency laparotomies.

The role of climate change in a developing threat: the case of bluetongue in Europe

There is a solid theoretical basis for expecting climate change to have a considerable effect on the infectious diseases of humans, animals and plants. Vector-borne diseases are the most likely to be affected. It is, however, rare to observe such impacts, as diseases are also influenced by many other drivers, some of which may have stronger effects over shorter time scales than climate change. Nevertheless, there is evidence that our warming climate has already influenced some animal diseases, of which bluetongue is considered a prime example. Bluetongue emerged dramatically in southern Europe after 1998 and in northern Europe from 2006. While the speed and scale of this emergence is a challenge to explain, there is evidence, principally from the development of climate-driven models, that recent climate change has played a significant role. Climate-driven models point to an increase in the risk of bluetongue transmission in Europe in recent decades, caused by an increased suitability of parts of southern Europe for the Afro-tropical biting midge, Culicoides imicola, as well as an increase in the vectorial capacity of indigenous Culicoides vectors in northern Europe. Farm-to-farm transmission models of bluetongue in England and Wales under predicted climatic conditions further suggest that, under high-emission scenarios, the scale of future outbreaks could far exceed those experienced to date. The role of climate change in the developing threat of animal disease is, therefore, likely to be economically and socially costly, unless lower emission targets can be set and followed.

Telephone-based CBT and the therapeutic relationship: The views and experiences of IAPT practitioners in a low-intensity service

WHAT IS KNOWN ON THE SUBJECT

There is a move towards the use of new ways of delivering mental health care, particularly via an increased use of telephone therapies. Although some studies have noted the advantages of telephone-delivered therapies (e.g., removing access barriers) and reported on equivalent therapeutic effects when compared to face-to-face, there are concerns about how telephone-based therapy adversely affects the therapeutic relationship.

WHAT THE PAPER ADDS TO EXISTING KNOWLEDGE

It contributes new knowledge regarding psychological practitioners' experience and views about using telephone-based therapies and how this affects the therapeutic relationship.

WHAT ARE THE IMPLICATIONS FOR PRACTICE

This paper provides data about the new practitioner workforce (IAPT Psychological Wellbeing Practitioners) and adds to a growing area of research regarding their clinical role. It has relevance for mental health nursing, because health services internationally and across the professions are exploring how telehealth can improve health care. This paper suggests that mental health services need to focus on what type of therapeutic relationship their practice facilitates and on offering transparency to service users. It concludes that telephone work in IAPT can accommodate a working alliance, but not other types of therapeutic relationship, which practitioners and service users hoped for. Services need to focus on what facilitates and inhibits deeper therapeutic closeness and connection.

ABSTRACT

Introduction Over-the-telephone (OTT)-delivered psychological therapies as an alternative method to face-to-face (F2F) are becoming more prevalent in mental health care. Research suggests a range of benefits of OTT use in therapy, but there are growing concerns about its consequences for the therapeutic relationship. This paper presents new knowledge regarding psychological practitioners' experience and views of OTT work and its potential effects on the therapeutic relationship in the context of the UK's Increasing Access to Psychological Therapy (IAPT) programme. Aim This paper presents IAPT practitioners' experiences and views of OTT work and its potential effects on the therapeutic relationship. Methods Completed questionnaires (exploring OTT versus F2F work) which were distributed to IAPT practitioners revealed a concern about the therapeutic relationship in OTT. To explore this further, nine in-depth semi-structured interviews with PWPs were conducted and the findings from this qualitative study are reported here. Results Practitioners noted OTT use facilitated access and flexibility for service users; however, they expressed some concern over the adverse effect of OTT on the therapeutic relationship. Discussion Although a working alliance was possible OTT, this research suggests the type of therapeutic relationship formed OTT in a "low contact-high volume" service such as IAPT needs to be better defined. By addressing this, dissonance which might arise between practitioner aims and the aims of IAPT can be reduced. This research also contributes to wider debates regarding mental health care and its provision in the UK. Implications for practice This paper concludes that mental health services need to focus on what type of therapeutic relationship their practice facilitates and to offer transparency to service users. The findings suggest that telephone work in IAPT can accommodate a working alliance, but not other types of therapeutic relationship, which practitioners and service users hoped for. Services need to offer a more nuanced understanding of the concept of a therapeutic relationship and focus on what facilitates and inhibits deeper therapeutic closeness and connection.