Intravenous Versus Rectal Contrast in CT Imaging for Abdominal Gunshot Wounds

CT imaging with rectal contrast historically has been a useful tool to help identify potential colon/rectal injuries; however, recent trends have shown less utilization of rectal contrast, in favor of IV contrast CT imaging alone. A retrospective review of patients with abdominal gunshot wounds was carried out to compare the two CT imaging techniques. An analysis of patients with colorectal injuries was conducted. Patients with IV contrast had a sensitivity of 84% and specificity of 96.8%. The PPV was 87.5% and NPV was 95.8%. In the IV and rectal contrast group, the sensitivity was 88.9% and specificity was 90.5%. The PPV was 80% and NPV was 95%. The proportion of missed injuries between the two was not statistically significant, p=0.18. The study suggests that while CT imaging with rectal contrast confidently identifies colon/rectal injuries, there are often secondary findings that will correctly prompt surgical exploration.

Research participants may not recall their participation but have a better understanding of alternative management options than patients in routine care

BACKGROUND

Patient understanding of care interventions, of the clinical uncertainty, and of their participation in clinical research is often poor. We hypothesized that compared to routine care, patients would better understand the prevailing uncertainty when they participated in research.

METHODS

A questionnaire was administered to patients at the time they attended a follow-up neurovascular clinic 4 to 52 weeks after a care episode where they did or did not participate in a clinical trial. Patients were not reminded whether they had previously participated in a clinical trial. Questions concerned their understanding of the risks/benefits of interventions, the availability of alternative options, whether their personal opinion was taken into consideration, the reason for the final decision, their confidence at having received the best management, and whether they had been research participants.

RESULTS

Between June 2019 and June 2020, 167 patients were recruited; 71 had truly been research participants, while 96 had not. A greater proportion of research patients were aware of the existence of management alternatives (65% versus 44%; P=0.008). Patients of both groups believed their personal opinion counted in the final decision (76% versus 70%), and patients were equally confident that they had received the best management (94%). Research patients believed they had participated in research 46% of the time, compared to 12% of routine care patients (P=0.003).

CONCLUSION

Many patients do not recall that they participated in a clinical trial, but they have a better understanding of the clinical uncertainty and of the availability of alternative management options.

Understanding the research-care demarcation and why it must be revised

BACKGROUND

A clean-cut separation between research and care was artificially created at the time of the Belmont report more than 40 years ago. The demarcation was initially controversial but eventually was implemented for political reasons. We examine why it must be revised.

METHODS

We review historical research scandals as well as the theoretical basis for the Belmont demarcation. We then discuss consequences on medical practice and propose an alternative.

DISCUSSION

Most research scandals involved abusing human beings supposedly for the sake of science. Belmont commissioners were aware the research/care problem was double-headed. While research subjects should be protected from abuse in the research context, patients need to be protected from unvalidated medical and surgical interventions in the care context. For political reasons the Commission recommended the regulation of research but to leave medical practice untouched. Thus the Commission had to distinguish research from care. The notion of 'generalizable knowledge' was introduced to define and regulate research, but the inadvertent result was that by trying to protect research subjects, the regulation has not only failed to protect all other patients, but also encouraged the widespread practice of unvalidated interventions within the care context. The notion of validated care should be re-introduced into a proper analysis of the care-research demarcation, for care research is an integral ingredient of a good medical practice.

CONCLUSION

The research-care demarcation should be revised to leave room for the validated/unvalidated care distinction. Care research, essential to guide medical practice, should be facilitated at all levels.

The Adapted Firesetting Assessment Scale: reliability and validity

BACKGROUND

The Adapted Firesetting Assessment Scale was developed for use with adults with developmental disabilities targeting fire-related factors thought to be associated with deliberate firesetting behaviour (i.e. attitudes towards fire, fire interest, fire normalisation, identification with fire and fire safety awareness). However, the psychometric properties of the scale are yet to be evaluated.

METHOD

The reliability, validity, comprehensibility, relevance and comprehensiveness of the Adapted Firesetting Assessment Scale were evaluated. Fifty-nine adults with developmental disabilities, some of whom had a history of firesetting, completed the Adapted Firesetting Assessment Scale on two occasions. Feedback about the questionnaire was sought from both participants and professionals.

RESULTS

The AFAS has acceptable internal consistency and excellent test-retest reliability. The attitudes towards fire, fire normalisation, poor fire safety subscales and total scores discriminated firesetters from non-firesetters. Content analysis of feedback indicated items of the AFAS were understood, relevant, accessible and comprehensible.

CONCLUSION

A larger study is needed to examine the factor structure of the AFAS.

A Systematic Review of Autistic People and the Criminal Justice System: An Update of King and Murphy (2014)

The purpose of this paper was to determine whether recommendations made by King & Murphy (Journal of Autism and Developmental Disorders 44:2717-2733, 2014) in their review of the evidence on autistic people in contact with the criminal justice system (CJS) have been addressed. Research published since 2013 was systematically examined and synthesised. The quality of 47 papers was assessed using the Mixed Methods Appraisal Tool. Findings suggest a limited amount of good quality research has been conducted that has focused on improving our understanding of autistic people in contact with the CJS since 2013. Methodological limitations make direct comparisons between autistic and non-autistic offenders difficult. Autistic people commit a range of crimes and appear to have unique characteristics that warrant further exploration (i.e., vulnerabilities, motivations for offending).

The Development of Acute Kidney Injury in Burn Patients Undergoing Computed Tomography With Intravenous Contrast

Acute kidney injury (AKI) is a major complication of significant burn injuries and a significant cause of patient morbidity and mortality. Patients that sustain traumatic burn injuries may require computed tomography (CT) imaging as part of their initial trauma management. This multicenter retrospective chart review of patients admitted to two level I trauma centers with ≥10% TBSA burns between 2014 and 2017 aims to determine if patients with greater than 10% TBSA burns that received CT imaging with intravenous contrast were more likely to develop acute kidney injury during their admission. A total of 439 patients were included in the study. The average age was 45.3 years and average TBSA was 23.2%. Sixty-seven of the 439 patients underwent CT scans with IV contrast on admission. The rate of AKI between patients who did or did not receive CT scans was not statistically significant (9.1 vs 6.0%, P = 0.40). Patients who developed an AKI had higher TBSA (45.6 vs 21.1%, P < .01), amount of fluids per TBSA given within the first 24 hours (457.4 vs 321.6, P < .01), and mortality (71.1 vs 6.2%, P < .01) than those who did not develop an AKI. There was no significant difference in the development of acute kidney injury in burn patients who received CT scans with IV contrast on admission. Although there is a risk of contrast induced nephropathy, the risk is not increased in burn patients and this should not prevent a thorough evaluation to rule out additional life-threatening injuries in the burn trauma patient.

183 A Systematic Review of Sample Size Calculations in High-Profile Surgical Trials That Use Patient-Reported Outcome Measures

Background

Patient reported outcome measures (PROMs) are increasingly recognised as a measure of treatment efficacy in randomised controlled trials (RCTs). It can be difficult to determine meaningful target differences in PROM scores for sample size calculations and this can risk over-recruitment and/or erroneous trial conclusions. The Difference ELicitation in TriAls (DELTA2) statement sets recommendations for sample size calculations in RCTs including target difference determination. We aimed to evaluate sample size calculations from high-profile surgical RCTs that used PROMs as their primary outcome, against DELTA2 standards, with a focus on target differences.

Method

Pubmed was systematically searched for surgical RCTs published in the five highest ranking journals, by Thomson Reuters impact factor, for medicine and surgery. Studies were included if surgery was the intervention and/or comparator arm, and a PROM was the primary outcome. Surgery was defined as using instrumentation to change macro-anatomy with the aim of improving health. Data were extracted with a piloted data collection sheet that included the DELTA2 reporting recommendations.

Results

Most target differences used in sample size calculations were determined with suboptimal techniques and target difference justification was overall poor. In this sample, £28 million of UK public research spending supported trials with poor target difference justification.

Conclusions

In this sample of trials, sample size calculations were generally not reported to DELTA2 standards. There was frequent use of sub-optimal methods to determine the target difference. This risks over-recruitment and/or erroneous trial conclusions. Clinicians should be aware of these potential pitfalls when interpreting published trials.

Real-time Detection of Patient Head Position and Cephalometric Landmarks from Neuro-Interventional Procedure Images Using Machine Learning for Patient Eye-Lens Dose Prediction

A deep learning (DL) model has been developed to estimate patient-lens dose in real-time for given exposure and geometric conditions during fluoroscopically-guided neuro-interventional procedures. Parameters input into the DL model for dose prediction include the patient head shift from isocenter and cephalometric landmark locations as a surrogate for head size. Machine learning (ML) models were investigated to automatically detect these parameters from the in-procedure fluoroscopic image. Fluoroscopic images of a Kyoto Kagaku anthropomorphic head phantom were taken at various known X (transverse) and Y (longitudinal) shifts, as well as different magnification modes, to create an image database. For each image, anatomical landmark coordinate locations were obtained manually using ImageJ and are used as ground-truth labels for training. This database was then used to train the two separate ML models. One ML model predicts the patient head shift in both the X and Y directions and the other model predicts the coordinates of the anatomical landmarks. From the coordinates, the distance between these anatomical landmarks is calculated, and input into the DL dose-prediction model. Model performance was evaluated using mean absolute error (MAE) and mean absolute percentage error (MAPE) for the head-shift and landmark-coordinate models, respectively. The goal is to implement these two separate models into the Dose Tracking System (DTS) developed by our group. This would allow the DTS to automatically detect the patient head size and position for eye-lens dose prediction and eliminate the need for manual input by the clinical staff.

141 New Guidelines to Reduce Unnecessary Blood Tests, Delayed Discharge and Costs Following Robot Assisted Radical Prostatectomy

Objectives

Routine postoperative blood tests (POBT) following robot assisted radical prostatectomy (RARP) are used to evaluate the impact of surgery on pre-existing co-morbidities and to detect early complications. This practice dates back to an era of open surgery, when blood loss and complication rates were higher. We propose new guidelines to improve the specificity of POBT.

Method

The cases of 1040 consecutive patients who underwent a primary or salvage RARP at two large tertiary urology centres in the United Kingdom were retrospectively reviewed to form new guidelines. The new guidelines were prospectively validated in a sample of 300 patients.

Results

Derivation Dataset: 3% and 5% had intra- and post-operative Clavien-Dindo complications, respectively. 15% had clinical concerns postoperatively. 0.9% required perioperative transfusion. 78% had routine blood tests without clinical concerns, none of whom developed a complication. 98% of complications were suspected by clinical judgement. 6% of patients had a discharge delay of ≥ 1 day due to delayed or incomplete blood tests. Validation Dataset: No significant difference existed in complication, clinical concern or transfusion rates between the derivation and validation datasets. Number of POBT requested reduced by 73% (p &lt; 0.001). The new guidelines improved POBT sensitivity for complications from 98% to 100% and specificity from 0% to 74%. Discharge delays reduced from 6% to 0% (p = 0.008). Cost savings were £178 per patient.

Conclusions

Postoperative complications and transfusion following RARP are rare. Routine POBT without clinical indication are unnecessary and inefficient. A guideline-based approach to POBT can reduce costs and optimise discharge without compromising patient safety or care.

1420 ViRtual prOficiency Based prOgression for Robotic Training (VROBOT): A Prospective Cohort Study Protocol

Introduction

Robotic surgery is an evolving field that requires specialist training. Historically, robotic surgery training has lacked standardisation. Recently, training centres have introduced proficiency-based modules and curriculums to certify and progress the skills of novice robotic surgeons. However, training tends to be self-directed and non-interactive. Limited interactive teaching does exist but can be inaccessible and expensive. We aim to validate the effectiveness of the current Fundamentals of Robotic Surgery (FRS) training curriculum with the addition of interactive virtual classroom teaching.

Method

16 novice surgical trainees will be assigned to two training groups. The interventions will be implemented following a one-week robotic skills induction. Both groups will receive access to the FRS curriculum for one week. The intervention group will additionally receive virtual classroom robotic skills training. The primary outcome will be the objective performance scores after training using a synthetic model based on task errors, time taken and contact pressure. In week 3, each group will receive the alternate intervention and objective performance scores will be measured to determine the trajectory of scores.

Results

Significant objective performance improvement following the intervention will be indicative of intervention quality.

Conclusions

This will be the first feasibility study evaluating the efficacy of interactive virtual robotic surgery training. It will determine the effect size of virtual classroom training on the development of basic robotic surgical skills in addition to the proficiency-based FRS curriculum. The findings will assist the development and implementation of further resource-efficient virtual robotic surgical skills training programs.

Complications of combination intranasal corticosteroids and anti-retroviral therapy

BACKGROUND

Intranasal corticosteroids are widely used for management of many upper airway diseases because of their ability to effectively deliver local relief of inflammation.

CASE REPORT

This paper presents the case of a 51-year-old man with human immunodeficiency virus treated with ritonavir who was started on fluticasone intranasal spray for presumed chronic rhinosinusitis. Months after starting this therapy, he developed symptoms of Cushing's syndrome and avascular necrosis of the shoulder due to the pharmacological interactions between fluticasone and ritonavir.

CONCLUSION

Although intranasal corticosteroids are deemed a low-risk route of drug administration, clinicians need to be vigilant in appropriately prescribing corticosteroids in the setting of drug potentiators, particularly in these high-risk patients. Alternative corticosteroids such as beclomethasone dipropionate should be considered in such cases.

Long term outcomes in older trauma patients admitted to the ICU: A prospective study

BACKGROUND

Prior studies have shown an increase in mortality in elderly patients when compared to their younger cohort.

METHODS

Level 1 trauma patients ≥50 years old were recruited upon admission to the ICU and prospectively followed. After an initial survey, inpatient data were collected and phone surveys were completed at 3 and 6 months.

RESULTS

100 patients were included. There was an 18% inpatient mortality. At 6 months, the mortality rate was 24%; 73% of surviving patients reported good health. 6-month nonsurvivors had a higher percentage requiring preinjury assistance with ambulation.

CONCLUSIONS

Severe trauma in patients ≥50 years of age carries a significant rate of mortality however survivors have good outcomes. Need for assistance with ambulation prior to injury is associated with 6 month mortality and could be used as a screening tool for interventions.

A Study of GP Workload and Satisfaction

Aims In this novel study in the Irish setting, we quantified the number items managed per General Practitioner (GP) consult, how each item is managed, and impact on a GP's job satisfaction. Methods Participating GPs at two surgeries completed a questionnaire - integrated into the practice management software - after each consultation that satisfied the inclusion criteria during a four-week period. Results Due to feasibility constraints, 500 of 857 (58.3%) completed questionnaires were randomly selected for our sample. GPs manage an average of 1.76 items per consultation. Older patients presented with more items. Greater number of presenting items led to less being managed on the day 71% (n=5) for 5 items vs. 95.2% (n= 246) for 1 item, longer consultation duration (mean = 14.63 minutes (4-45) and decreased GP satisfaction, mean 8/10 (2-10). Conclusion Increasing the number of items in a GP consultation has a statistically significant effect on duration of consultation, how each item is managed, and even GP satisfaction.

O43 Virtual: virtual interactive surgical skills classroom: a randomized controlled trial (protocol)

Introduction

High costs and inaccessibility are significant barriers to face-to-face basic surgical skills (BSS) training. Virtual classrooms enable the combination of computer-based learning with interactive expert instruction. They may optimise resources and increase accessibility, facilitating larger-scale training with a similar educational benefit. We aim to evaluate the efficacy of virtual BSS classroom training compared to both non-interactive video and face-to-face teaching.

Method

72 medical students will be randomly assigned to three equal intervention groups based on surgical skills experience and confidence. Interventions will be implemented following an instructional video. Group A will practice independently, Group B will receive face-to-face training, and Group C will attend a virtual classroom. Participants will be recorded placing three interrupted sutures with hand tied knots pre- and post-intervention. Objective Structured Assessment of Technical Skills (OSATS) will be blind marked by two experts.

Result

Change in confidence, time to completion and a novel granular performance score will also be measured. Each intervention’s feasibility and accessibility will be assessed. Significant improvement in OSATS within groups will be indicative of intervention quality. Difference in improvement between groups will determine the relative performance of the interventions.

Conclusion

This will be the largest randomised control trial investigating virtual BSS classroom training. It will serve as a comprehensive appraisal of the suitability of virtual classrooms as an alternative to face-to-face training. The findings will assist the development and implementation of further resource-efficient training programs during the COVID-19 pandemic and beyond.

Take-home Message

This is the first RCT assessing virtual basic surgical skill classroom training and serves as a comprehensive appraisal of the suitability of virtual classrooms as an alternative to face-to-face training. The findings will assist the development and implementation of further resource-efficient training programs during the COVID-19 pandemic and in the future.

O50 New guidelines to reduce unnecessary blood tests, delayed discharge and costs following robot assisted radical prostatectomy

Introduction

Routine postoperative blood tests (POBT) are used to evaluate the impact of surgery on pre-existing co-morbidities and to detect early complications. This practice dates back to an era of open surgery, when blood loss and complication rates were higher. We propose new guidelines to improve the specificity of POBT.

Method

The cases of 1040 consecutive patients who underwent a primary or salvage RARP at two large tertiary urology centres in the United Kingdom were retrospectively reviewed, and new guidelines were designed. The guidelines were prospectively validated in a cohort of 300 patients.

Result

Derivation Dataset 3% and 5% had intra- and post-operative Clavien-Dindo complications, respectively. 15% had clinical concerns postoperatively. 0.9% required perioperative transfusion. 78% had routine blood tests without clinical concerns, none of whom developed a complication. 98% of complications were suspected by clinical judgement. 6% of patients had a discharge delay of ≥ 1 days due to delayed or incomplete blood tests.

Validation Dataset No significant difference existed in complication, clinical concern or transfusion rates between the derivation and validation datasets. New guidelines improved sensitivity for complications from 98% to 100% and specificity from 0% to 74%. The number of blood tests requested reduced by 73% (P &lt; 0.001). Discharge delays reduced from 6% to 0% (P = 0.008). Cost savings were £178 per patient.

Conclusion

Postoperative complications and transfusion following RARP are rare. Routine POBT without clinical indication are unnecessary and inefficient. A guideline-based approach to POBT can reduce costs and optimise discharge without compromising patient safety or care.

Take-home Message

Routine postoperative blood tests following robot assisted radical prostatectomy are often unnecessary. A guideline-based approach can reduce costs and optimise patient care.

Preferences and Predictions Regarding Palliative Care in the Trauma Intensive Care Unit

INTRODUCTION

In the older intensive care unit (ICU) trauma population, it is common to have to make decisions about end-of-life. We sought to demonstrate uncertainty of patients and providers in this area.

METHODS

Our study is a prospective observational study of trauma patients 50 years and older admitted to the ICU. Patients or surrogates completed a survey including questions regarding end-of-life. Team members were surveyed with their expectation for patient outcome and appropriateness of palliative or comfort care. Patients were followed up for 6 months. Chi-square analysis and Fisher's exact test were performed.

RESULTS

100 patients had data available for analysis. Surveys were completed by the patient for 39 while a surrogate completed the survey for 61 patients. There was a significant increase in uncertainty if a surrogate answered or if there had been no prior discussions about end-of-life. Nurse, resident, and attending predictions about hospital survival were similar with all groups predicting survival in 82%. 6-month survivors were only predicted to be alive 75% of the time. Ideas about comfort care were similar but there was more variation regarding a palliative care consult with nurses saying yes in 27% of surveys while physicians only said yes in 18%.

CONCLUSIONS

The significantly higher rates of uncertainty for both surrogates or in cases where no prior discussion had been had highlight the importance of having more conversations about end-of-life and documentation of advance directives prior to traumatic events. The difference in team member ideas about palliative care demonstrates a need for improved team communication.

Atmospheric Carbon and Transport - America (ACT-America) Data Sets: Description, Management, and Delivery

The ACT-America project is a NASA Earth Venture Suborbital-2 mission designed to study the transport and fluxes of greenhouse gases. The open and freely available ACT-America data sets provide airborne in situ measurements of atmospheric carbon dioxide, methane, trace gases, aerosols, clouds, and meteorological properties, airborne remote sensing measurements of aerosol backscatter, atmospheric boundary layer height and columnar content of atmospheric carbon dioxide, tower-based measurements, and modeled atmospheric mole fractions and regional carbon fluxes of greenhouse gases over the Central and Eastern United States. We conducted 121 research flights during five campaigns in four seasons during 2016-2019 over three regions of the US (Mid-Atlantic, Midwest and South) using two NASA research aircraft (B-200 and C-130). We performed three flight patterns (fair weather, frontal crossings, and OCO-2 underflights) and collected more than 1,140 h of airborne measurements via level-leg flights in the atmospheric boundary layer, lower, and upper free troposphere and vertical profiles spanning these altitudes. We also merged various airborne in situ measurements onto a common standard sampling interval, which brings coherence to the data, creates geolocated data products, and makes it much easier for the users to perform holistic analysis of the ACT-America data products. Here, we report on detailed information of data sets collected, the workflow for data sets including storage and processing of the quality controlled and quality assured harmonized observations, and their archival and formatting for users. Finally, we provide some important information on the dissemination of data products including metadata and highlights of applications of ACT-America data sets.

Obturator hernia: a case report

Background

Obturator hernia is rare and accounts for less than 1% of all abdominal wall hernias. It represents a diagnostic challenge due to its nonspecific signs and symptoms.

Case presentation

We present a case of an 89-year-old caucasian female with a 12-hour history of right medial thigh pain. Computed tomography scan revealed a right obturator hernia with small bowel obstruction. The hernia was successfully repaired laparoscopically without any need for small bowel resection. She was discharged on postoperative day 2 with an uneventful recovery and zero complications.

Conclusion

This case report highlights the importance of rapid diagnosis and repair of obturator hernia even in the setting of an improving clinical picture. It also demonstrates the safety of laparoscopic repair in this setting.

Estimation of Patient Eye-Lens Dose During Neuro-Interventional Procedures using a Dense Neural Network (DNN)

The patient's eye-lens dose changes for each projection view during fluoroscopically-guided neuro-interventional procedures. Monte-Carlo (MC) simulation can be done to estimate lens dose but MC cannot be done in real-time to give feedback to the interventionalist. Deep learning (DL) models were investigated to estimate patient-lens dose for given exposure conditions to give real-time updates. MC simulations were done using a Zubal computational phantom to create a dataset of eye-lens dose values for training the DL models. Six geometric parameters (entrance-field size, LAO gantry angulation, patient x, y, z head position relative to the beam isocenter, and whether patient's right or left eye) were varied for the simulations. The dose for each combination of parameters was expressed as lens dose per entrance air kerma (mGy/Gy). Geometric parameter combinations associated with high-dose values were sampled more finely to generate more high-dose values for training purposes. Additionally, dose at intermediate parameter values was calculated by MC in order to validate the interpolation capabilities of DL. Data was split into training, validation and testing sets. Stacked models and median algorithms were implemented to create more robust models. Model performance was evaluated using mean absolute percentage error (MAPE). The goal for this DL model is that it be implemented into the Dose Tracking System (DTS) developed by our group. This would allow the DTS to infer the patient's eye-lens dose for real-time feedback and eliminate the need for a large database of pre-calculated values with interpolation capabilities.

Evaluating survey methods for bat roost detection in ecological impact assessment

The disturbance, damage and destruction of roosts are key drivers of bat population declines worldwide. In countries where bats are protected by law, bat roost surveys are often required to inform ecological impact assessments. Yet, evidence‐based information on survey methodology to detect bat roosts is crucially lacking, and failing to detect a roost can lead to serious errors during decision‐making processes. Here, we assess the efficacy of bat roost surveys in buildings as implemented in the UK. These consist of a daytime inspection of buildings, followed by a series of acoustic surveys at dusk/dawn if during the daytime inspection evidence of bats is found, or if the absence of bats cannot be verified. We reviewed 155 ecological consultants’ reports to (1) compare survey outcome between daytime inspection and acoustic surveys and (2) determine the minimum sampling effort required during acoustic surveys to be confident that no bats are roosting within a building. We focused on two genera of bats most frequently found in buildings in Europe – Pipistrellus (crevice roosting species with high‐intensity echolocation calls that can be easily detected by ultrasound detectors) and Plecotus (species that roost in open spaces and which emit faint echolocation calls that are difficult to detect). Daytime inspections were efficient in detecting open‐roosting species such as Plecotus species but were likely to miss the presence of crevice‐dwelling ones (here Pipistrellus species) which may lead to erroneous conclusions if no acoustic surveys are subsequently prescribed to confirm their absence. A minimum of three and four acoustic surveys are required to be 95% confident that a building does not host a roost of Pipistrellus species and Plecotus species, respectively, thus exceeding current recommendations. Overall, we demonstrated that reports submitted as part of an ecological impact assessment provide suitable data to test and improve survey methods.

Gastrointestinal Bleeding in Mechanical Cardiac Support

BACKGROUND

Mechanical cardiac support (MCS) is a lifesaving therapy option in patients with heart failure and other medical disorders. However, there is an associated risk of gastrointestinal bleeding (GIB). The goal of this study was to determine GIB incidence and associated risk factors.

METHODS

All patients at one institution from 2009 to 2018 under durable and nondurable support were retrospectively reviewed for GIB during their MCS period. Clinical records were evaluated for patient demographics, GIB characteristics, and interventions. Univariate and multivariate analyses were performed to compare patient groups.

RESULTS

A total of 427 patients were reviewed, with 111 (25.9%) patients representing 218 episodes of GIB during our study period. The incidence rate from support initiation to GIB was 44.9% by 6 months and 60.6% in 12 months, occurring at a mean of 216.7 days. Higher rates of bleeding were found in patients with hypertension (82% vs 71.5%; P = .03) and diabetes mellitus (62.2% vs 38.3%; P < .0001), as well as pulmonary (48.7% vs 35.4%; P = .014), hepatic (21.6% vs 10.4%; P = .003), and renal disease (48.7% vs 37.3%; P = .037). Endoscopy revealed an upper GI source in 56% (n = 123) of bleeds. The most common etiology of bleeding included angiodysplasia/vascular malformation (35.7%). Therapeutic intervention was performed in 109 (50%) cases, with only 1 surgical intervention.

DISCUSSION

Overall, GIB can be a significant adverse event in patients under mechanical cardiac support, so proper management of anticoagulation and early endoscopy evaluation remains of great importance.

Do images of dietitians on the Internet reflect the profession?

BACKGROUND

The image of dietitians presented on the Internet shapes public perception of the profession, which in turn may influence engagement with professionals. The aim was to describe the portrayal of the dietetic profession on the Internet and how this aligns with international professional demographics.

METHODS

In this cross-sectional observational study, images appearing in two Google image searches using the word 'dietitian' were analysed for content by two independent researchers. A coding framework was used to identify personal characteristics of professionals and others presented in the image, as well as the work setting. These were compared to demographic data of members of professional associations in Australia, the United Kingdom (UK) and the United States of America (USA).

RESULTS

The dietitian portrayed in the images (n = 339) was most often female (88%), Caucasian (72%), aged between 26-39 years (63%), pictured alone (78%), pictured with food (78%) and in a setting that could not be determined (76%). The age and gender profile presented matches the characteristics of the international workforce; however, there was an absence of images illustrating dietitians in authentic work roles.

CONCLUSIONS

The images resulting from an online search for 'dietitian' do not fully illustrate the profession. There are opportunities to create and share authentic images online that show the breadth of work roles and diversity of professionals' age, gender, cultural background and size.

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.

Use of Early Gastrografin Small Bowel Follow-through in Small Bowel Obstruction Management

Small bowel follow-through (SBFT) is a diagnostic tool commonly used in the management of patients with small bowel obstruction (SBO). This study assessed whether early implementation of Gastrografin SBFT would reduce the time to resolution of the SBO and decrease the time to operative intervention. In this retrospective chart review, 103 patients with the clinical diagnosis of adhesive SBO were evaluated. End points of the study were resolution of SBO with non-operative management or operative intervention. The patient group that had received a SBFT was then compared with those that did not receive a SBFT. There were 103 patients with adhesive SBO who met inclusion criteria for this study. Seventy-two of 103 patients had undergone Gastrografin SBFT and 31 did not. In the SBFT group, mean time to the operating room was 1.0 days after SBFTs, whereas in the group that did not receive SBFT, it was 3.7 days ( P < 0.0001). Mean time to nonoperative resolution of SBO in the SBFT group was 1.8 days and 4.7 days in the no SBFT group ( P < 0.0001). There were no Gastrografin-related complications. Obtaining Gastrografin SBFT in patients with adhesive SBO leads to both a shorter time in identifying the need for operative intervention and to resolution of SBO with nonoperative management. SBFT seems to be a more definitive assessment of whether an SBO will resolve on its own or if operative intervention is necessary.

FRI0421 RATES OF PROGRESSION DIFFER BETWEEN STRUCTURAL PHENOTYPES OF KNEE OSTEOARTHRITIS: A SECONDARY ANALYSIS FROM THE FNIH COHORT

Background:

Imaging plays an important role in determining structural disease severity and potential suitability of patients recruited to disease-modifying osteoarthritis drug (DMOAD) trials. It has been suggested that there may be three main structural phenotypes in OA, i.e., inflammation, meniscus/cartilage and subchondral bone. These may progress differently and may represent distinct tissue targets for DMOAD approaches.

Objectives:

To stratify the Foundation for National Institutes of Health Osteoarthritis Biomarkers Consortium (FNIH) cohort, a well-defined subsample of the larger Osteoarthritis Initiative (OAI) study, into distinct structural phenotypes based on semiquantitative MRI assessment and to determine their risk for progression over 48 months.

Methods:

The FNIH was designed as a case-control study with knees showing either 1) radiographic and pain progression (i.e., “composite” cases), 2) radiographic progression only (“JSL”), 3) pain progression only, and 4) neither radiographic nor pain progression. MRI of both knees was performed on 3 T systems at the four OAI clinical sites. Two musculoskeletal radiologists read the baseline MRIs according to the MOAKS scoring system. Knees were stratified into subchondral bone, meniscus/cartilage and inflammatory phenotypes1. A secondary, less stringent definition for inflammatory and meniscus/cartilage phenotype was used for sensitivity analyses. The relation of each phenotype to risk of being in the JSL or composite case group compared to those not having that phenotype was determined using conditional logistic regression. Only KL2 and 3 and those without root tears were included.

Results:

485 knees were included. 362 (75%) did not have any phenotype, while 95 (20%) had the bone phenotype, 22 (5%) the cartilage/meniscus phenotype and 19 (4%) the inflammatory phenotype. The bone phenotype was associated with a higher risk of the JSL and composite outcome (OR 1.81;[95%CI 1.14,2.85] and 1.65; 95%CI [1.04,2.61]) while the inflammatory (OR 0.96 [95%CI 0.38,2.42] and 1.25; 95%CI [0.48,3.25]) and the meniscus/cartilage phenotypes were not (OR 1.30 95%CI [0.55,3.07] and 0.99; 95%CI [0.40,2,49]).

In sensitivity analyses, the bone phenotype and having two phenotypes (vs. none) were both associated with increased risk of experiencing the composite outcome (bone: OR 1.65; 95% CI 1.04, 2.61; 2 phenotypes: OR 1.87; 95% CI 1.11, 3.16.

Conclusion:

The bone phenotype was associated with increased risk of having both radiographic and pain progression together, or radiographic progression alone, whereas the inflammatory phenotype or meniscus/cartilage phenotype each individually were not associated with either outcome. Phenotypic stratification appears to provide insights into risk for structural or composite structure plus pain progression, and therefore may be useful to consider when selecting patients for inclusion in clinical trials.

References:

[1]Roemer FW, Collins J, Kwoh CK, et al. MRI-based screening for structural definition of eligibility in clinical DMOAD trials: Rapid OsteoArthritis MRI Eligibility Score (ROAMES). Osteoarthritis Cartilage 2020;28(1):71-81

Disclosure of Interests:

Frank Roemer: None declared, Jamie Collins Consultant of: Boston Imaging Core Lab (BICL), LLC., Tuhina Neogi Grant/research support from: Pfizer/Lilly, Consultant of: Pfizer/Lilly, EMD-Merck Serono, Novartis, Michel Crema: None declared, Ali Guermazi Consultant of: AventisGalapagos, Pfizer, Roche, AstraZeneca, Merck Serono, and TissuGene

Oncologic outcomes of patients with incidental prostate cancer who underwent RARC: a comparison between nerve sparing and non-nerve sparing approach

BACKGROUND

Incidental Prostate cancer (iPCa) is a relatively common finding during histopathological evaluation of radical cystectomy (RC) specimens. To reduce the high impact of RC on erectile function, several sexual-preserving techniques have been proposed. The aim of this study was to evaluate and compare the oncologic outcomes of patients with iPCa who underwent nerve spring and no-nerve sparing robot-assisted radical cystectomy (RARC).

METHODS

The clinicopathologic data of male patients who underwent RARC at our institution between 2006 and 2016 were retrospectively analysed. Patients with iPCa at definitive pathological examinations were stratified in two groups, according to the preservation of the neurovascular bundles (nerve sparing vs no nerve sparing). Significant PCa was defined as any Gleason score ≥ 3 + 4. Biochemical recurrence (BR) was defined as a sustained PSA level > 0.2 ng/mL on two or more consecutive appraisals. BR rate was assessed only in patients with incidental prostate cancer and at least 2 years of follow-up. Differences in categorical and continuous variables were analysed using the chi-squared test and the Mann-Withney U test, respectively. Biochemical recurrence curves were generated using the Kaplan-Meier method and compared with the Log-rank test.

RESULTS

Overall, 343 male patients underwent RARC for bladder cancer within the study period. Nerve-sparing surgery was performed in 143 patients (41%), of these 110 had at least 2 years of follow up after surgery. Patients who underwent nerve-sparing surgery were significantly younger (p < 0.001). Clinically significant PCa was found in 24% of patients. No significant differences regarding preoperative PSA value (p = 0.3), PCa pathological stage (p = 0.5), Gleason score (p = 0.3) and positive surgical margin rates (p = 0.3) were found between the two groups. After a median follow-up of 51 months only one patient, in the no-nerve-sparing group had developed a biochemical recurrence (p = 0.4).

CONCLUSIONS

In our series most of the iPca detected in RC specimens can be considered as insignificant with a low rate of BR (0.9%). Nerve-sparing RARC is a safe procedure which did not affect oncological outcomes of patients with iPCa.

Failure of Nonoperative Management of Splenic Injuries in Trauma Patients on Anticoagulation

Although nonoperative management or embolization with preservation of splenic tissue is preferable, there is a significant risk of continued bleeding ultimately requiring splenectomy. It has been established that elderly patients on anticoagulation (AC) have an increased risk of splenic injury, but there are little data to show whether AC plays a role in outcomes of splenic injury in the setting of trauma. This is a retrospective cohort study, including 168 adults aged 50 to 79 years who presented as a trauma patient to Sentara Norfolk General Hospital from January 1, 2010, to March 31, 2018. The primary outcome is the management of the splenic injury. Of the 168 patients, 30 were presently taking AC at the time of their injury, and 138 were not taking any AC. These groups were similar in average Injury Severity Score, average grade of splenic injury, and average systolic blood pressure on arrival. However, the groups differed significantly in age and hemoglobin on arrival. We found that patients taking AC at the time of injury underwent splenectomy 23.3 per cent of the time, whereas patients not taking AC underwent splenectomy 11.6 per cent of the time ( P = 0.045). Patients taking AC failed nonoperative management 20 per cent of the time, whereas patients not taking AC failed 0.7 per cent of the time ( P < 0.05). We found that patients taking AC at the time of their traumatic injury were more likely to undergo splenectomy than patients not taking AC. We also found that patients taking AC were more likely to fail nonoperative management.

Expert consensus on a train-the-trainer curriculum for robotic colorectal surgery

AIM

Robotic techniques are being increasingly used in colorectal surgery. There is, however, a lack of training opportunities and structured training programmes. Robotic surgery has specific problems and challenges for trainers and trainees. Ergonomics, specific skills and user-machine interfaces are different from those in traditional laparoscopic surgery. The aim of this study was to establish expert consensus on the requirements for a robotic train-the-trainer curriculum amongst robotic surgeons and trainers.

METHOD

This is a modified Delphi-type study involving 14 experts in robotic surgery teaching. A reiterating 19-item questionnaire was sent out to the same group and agreement levels analysed. A consensus of 0.8 or higher was considered to be high-level agreement.

RESULTS

Response rates were 93-100% and most items reached high levels of agreement within three rounds. Specific requirements for a robotic faculty development curriculum included maximizing dual-console teaching, theatre team training, nontechnical skills training, patient safety, user-machine interface training and telementoring.

CONCLUSION

A clear need for the development of a train-the-trainer curriculum has been identified. Further research is needed to assess feasibility, effectiveness and clinical impact of a robotic train-the-trainer curriculum.

Failure of Nonoperative Management of Splenic Injuries in Trauma Patients on Anticoagulation

Although nonoperative management or embolization with preservation of splenic tissue is preferable, there is a significant risk of continued bleeding ultimately requiring splenectomy. It has been established that elderly patients on anticoagulation (AC) have an increased risk of splenic injury, but there are little data to show whether AC plays a role in outcomes of splenic injury in the setting of trauma. This is a retrospective cohort study, including 168 adults aged 50 to 79 years who presented as a trauma patient to Sentara Norfolk General Hospital from January 1, 2010, to March 31, 2018. The primary outcome is the management of the splenic injury. Of the 168 patients, 30 were presently taking AC at the time of their injury, and 138 were not taking any AC. These groups were similar in average Injury Severity Score, average grade of splenic injury, and average systolic blood pressure on arrival. However, the groups differed significantly in age and hemoglobin on arrival. We found that patients taking AC at the time of injury underwent splenectomy 23.3 per cent of the time, whereas patients not taking AC underwent splenectomy 11.6 per cent of the time (P = 0.045). Patients taking AC failed nonoperative management 20 per cent of the time, whereas patients not taking AC failed 0.7 per cent of the time (P < 0.05). We found that patients taking AC at the time of their traumatic injury were more likely to undergo splenectomy than patients not taking AC. We also found that patients taking AC were more likely to fail nonoperative management.

Early Use of a Chest Trauma Protocol in Elderly Patients with Rib Fractures Improves Pulmonary Outcomes

Rib fractures are among the most common injuries identified in blunt trauma patients. Morbidity increases with increasing age and increasing number of rib fractures. The use of noninvasive ventilation has been shown to be helpful as a rescue technique avoiding intubation in patients who have become hypoxemic but little data with regard to its use to prophylactically prevent worsening respiratory status are available. We developed a chest trauma protocol for our “elderly” (>45 years) trauma patients and sought to determine whether this would improve pulmonary outcomes. We retrospectively reviewed our elderly chest trauma patients one year before (CTRL) and nine months after implementation (STU) of the chest trauma protocol. The protocol consisted of intravenous narcotics, oral nonsteroidal anti-inflammatory drugs, prophylactic noninvasive ventilation, and measurements of incentive spirometry. In the control year, there were 176 patients meeting study criteria, whereas 140 met the criteria in the STU group. The CTRL group had 11 unplanned ICU admissions (rate 0.063), six unplanned intubations (rate 0.034), and eight patients diagnosed with pneumonia (rate 0.045). These rates decreased in the STU group to two unplanned ICU admissions (0.014, P = 0.044), one unplanned intubation (rate 0.007, P = 0.138), and no patients with pneumonia (0.0, P = 0.010). Our chest trauma protocol has significantly decreased adverse pulmonary events in our older blunt chest trauma population with multiple rib fractures. This protocol has become our standard procedure for patients older than 45 years admitted with rib fractures.

Early Use of a Chest Trauma Protocol in Elderly Patients with Rib Fractures Improves Pulmonary Outcomes

Rib fractures are among the most common injuries identified in blunt trauma patients. Morbidity increases with increasing age and increasing number of rib fractures. The use of noninvasive ventilation has been shown to be helpful as a rescue technique avoiding intubation in patients who have become hypoxemic but little data with regard to its use to prophylactically prevent worsening respiratory status are available. We developed a chest trauma protocol for our "elderly" (>45 years) trauma patients and sought to determine whether this would improve pulmonary outcomes. We retrospectively reviewed our elderly chest trauma patients one year before (CTRL) and nine months after implementation (STU) of the chest trauma protocol. The protocol consisted of intravenous narcotics, oral nonsteroidal anti-inflammatory drugs, prophylactic noninvasive ventilation, and measurements of incentive spirometry. In the control year, there were 176 patients meeting study criteria, whereas 140 met the criteria in the STU group. The CTRL group had 11 unplanned ICU admissions (rate 0.063), six unplanned intubations (rate 0.034), and eight patients diagnosed with pneumonia (rate 0.045). These rates decreased in the STU group to two unplanned ICU admissions (0.014, P = 0.044), one unplanned intubation (rate 0.007, P = 0.138), and no patients with pneumonia (0.0, P = 0.010). Our chest trauma protocol has significantly decreased adverse pulmonary events in our older blunt chest trauma population with multiple rib fractures. This protocol has become our standard procedure for patients older than 45 years admitted with rib fractures.

Abstract P1-09-13: A real world evidence study of BRCA mutations and survival in HER2-negative breast cancer

Background: Limited data exist on the natural history (treated with standard of care) of metastatic breast cancer (mBC) characterized by germline breast cancer susceptibility gene mutations (gBRCAm). Real-world data examining survival for patients with gBRCAm mBC, overall and separated into gBRCA1m and gBRCA2m, compared to gBRCA wild type (wt) mBC, can help to clarify the prognostic outlook associated with the gBRCA mutation.

Methods: Adults with human epidermal growth factor receptor 2 negative (HER2-) mBC diagnosed from January 2013 – August 2017 were retrospectively selected from the Flatiron Health Oncology electronic medical record database. Patients were classified as having gBRCA1m, gBRCA2m, or gBRCAwt disease. Those who did not receive the genetic testing or who had equivocal results were classified as gBRCA unknown. Overall survival (OS) was calculated from first diagnosis of mBC, as well as from the start of first- and second-line therapy for metastatic disease. Lines of therapy included both hormonal and systemic therapies. Kaplan-Meier analyses provided median OS with 95% confidence interval (CI). Unadjusted log-rank tests compared OS between gBRCA1m and gBRCA2m, and between overall gBRCAm and gBRCAwt.

Results: Of 8,080 patients selected, mean age at first mBC diagnosis was 64 years, 98.7% were female, and 82.0% had evidence of hormone receptor positive disease. gBRCA status was known for 1,852 (22.9%) of patients, of whom 89 (4.8%) had gBRCA1m, 152 (8.2%) had gBRCA2m, and 8 (0.4%) had both gBRCA mutations. Patients with known gBRCA status were younger, with mean ages of 52 years for gBRCAm, 55 years for gBRCAwt, and 67 years for gBRCA unknown. Hormone receptor positive disease was less common among those with known gBRCA status (71.9%, 77.2%, and 83.6% for gBRCAm, gBRCAwt, and gBRCA unknown, respectively). Median (95% CI) OS from mBC diagnosis was 22 (14 - 26) months for gBRCA1m and 30 (27 - 37) months for gBRCA2m (p = 0.01), though numbers were quite small by the median timepoint. Overall gBRCAm disease was associated with median survival of 28 (25 - 32) months, compared to 32 (30 - 35) months for gBRCAwt (p = 0.07); survival was similar between groups for the first 24 months but declined thereafter in the gBRCAm group. Similar patterns were observed for OS after the start of first- and second-line therapy, although no comparisons were significant. Further analyses will present adjusted results and comparisons with outcomes for the patients with gBRCA unknown.

Conclusions: This real-world study of patients receiving care in largely community oncology clinics suggests that survival after diagnosis of mBC is reduced in patients with gBRCA1m compared to gBRCA2m disease and may be reduced in gBRCAm mBC overall. Effective treatments targeted for the gBRCAm subtypes of mBC appear to be needed.

Citation Format: Dalvi T, McLaurin K, Briceno J, Nordstrom B, Bennett J, Hettle R, Murphy B, Collins J, McCutcheon S. A real world evidence study of BRCA mutations and survival in HER2-negative breast cancer [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P1-09-13.

Two-minute versus 6-minute walk distances during 6-minute walk test in neuromuscular disease: Is the 2-minute walk test an effective alternative to a 6-minute walk test?

Functional tests such as Motor Function Measure-32 (MFM-32), supine to stand, ascend/descend stairs permit the assessment of task-specific motor function in neuromuscular disease (NMD). The 6-min walk test (6MWT), though functional, is primarily used to assess endurance and disease progression in children with neuromuscular disorders. Barriers to 6MWT administration, in this population, can include reduced attention span due to age and inability to tolerate test length due to weakness. We propose task-specific functional deficits are related to endurance. Additionally, the 2-min walk test (2MWT) could effectively replace the 6MWT in this population. Seventy-seven participants, ages 5-18, with a variety of neuromuscular disorders performed the 6MWT, timed functional tests (TFT), and the MFM-32. Correlation and paired t-test analyses were used to compare the distance walked in the first 2 min (2MWD) to the distance walked in the entire 6 min (6MWD) and to the functional outcome measures above. The 2MWD strongly correlated with 6MWD and the other outcome measures. Paired t-test analysis also showed that the 2MWD did not differ from the distance walked in the last 2 min of the 6MWT. Although equivalence testing could not reject the claim that this difference exceeded the upper practical limit of 9.5 m, it only showed a modest overestimation of the 4-6MWD compared with the 2MWD. Together, our results support the ability of the 2MWD to predict the 6MWD, specifically in the pediatric neuromuscular disease population.