Mechanical load applied by Intraosseous Transcutaneous Amputation Prosthesis (ITAP) during walking on level and sloped treadmill: A case study

This proof of concept study presents a method to collect and analyse kinetic data from one participant with a transfemoral amputation fitted with a percutaneous osseointegrated implant walking on a level and sloped treadmill. We describe the construction of and results from a bespoke wireless six axis load cell built into one participant's prosthetic assembly. The load cell does not clinically compromise the participant in any way and is an initial milestone in the development of a light-weight wireless load cell for use with percutaneous osseointegrated implants. In this case, it is the first time that kinetic data from a participant fitted with an Intraosseous Transcutaneous Amputation Prosthesis has been published. We propose that the data can be used to model the load transfer to the host bone, with several clinically significant applications. The raw dynamic data are made available and quasi-static load cases for each functional phase of gait are presented. Peak forces obtained in the medio-lateral (X), cranio-caudal (Y) and antero-posterior (Z) axes over level ground respectively were -243.8 N (0.24 BW), 1321.5 N (1.31 BW) and -421.8 N (0.42 BW); uphill were -141.0 N (0.14 BW), 1604.2 N (1.59 BW), -498.1 N (0.49 BW); downhill were -206.0 N (0.20 BW), 1103.9 N (1.09 BW), -547.2 N (0.54 BW). The kinetics broadly followed able bodied gait patterns with some gait strategies consistent in participants with other implant designs or prosthetic socket connections, for example offloading the artificial limb downhill.

Unveiling the Anthelminthic Potential of Merremia vitifolia Stem through in Vitro and in Silico Approach

This study aimed to assess the anthelmintic activity of methanol extracts from Merremia vitifolia stems using a combination approach encompassing experimental, in vitro, and in silico evaluations. Despite the well-recognized pharmacological properties of M. vitifolia, its potential as an anthelmintic agent remained unexplored. This plant's anthelmintic potential was assessed on adult earthworms (Pheretima posthuma), revealing a dose-dependent reduction in spontaneous motility leading to paralysis and eventual mortality. The most effective dose of M. vitifolia (200 mg/ml) for anthelmintic effects on Pheretima posthuma was identified. Complementary in silico investigations were also conducted, employing Autodock PyRx 0.8 for docking studies of reported M. vitifolia compounds. Notably, quercetin emerged as a promising candidate with superior binding energies against β-tubulin (-8.3 Kcal/mol). Moreover, this comprehensive research underlines the anthelmintic potential of Merremia vitifolia stem extract and highlights quercetin as a noteworthy compound for further investigation in the quest for novel anthelmintic agents.

Effect of membrane stabilizers on semen quality and sperm membrane protein expression during cryopreservation of goat semen

BACKGROUND

Semen cryopreservation is a complex process during which there is alteration in the expression of sperm and seminal plasma proteins, molecular weight of protein or loss of membrane proteins during the process. In order to compensate for these changes, different membrane stabilizers are used in freezing semen extenders. However, there is scarcity of such studies during cryopreservation of goat semen.

OBJECTIVE

To investigate the effect of membrane stabilizers on sperm membrane protein expression during cryopreservation of goat semen.

MATERIALS AND METHODS

A total of 36 semen ejaculates from nine Assam Hill Goat bucks aged 2 to 2.5 years was collected by artificial vagina method. Three membrane stabilizers, each at two different concentrations viz. 50 and 80 mM sucrose, 50 and 100 mM trehalose, and 100 and 150 ng per mL IGF-1 (insulin-like growth factor 1 protein) were added to Tris-citric acid fructose egg yolk glycerol (TCFEYG) extender and semen samples were cryopreserved. The sperm membrane protein profile was studied in fresh and cryopreserved semen by SDS-PAGE.

RESULTS

SDS- PAGE of sperm membrane extract of fresh semen revealed the presence of 24 protein bands with molecular weights ranging from 10 kDa to 240 kDa. Samples supplemented with 50 mM sucrose and 80 mM sucrose revealed 21 protein bands with molecular weights ranging from 10 kDa to 240 kDa. All the 21 protein bands were same as those observed in the sperm membrane of fresh spermatozoa, except that the 23 kDa, 29 kDa and 42 kDa bands were absent in frozen semen. Similarly, frozen semen extended with 50 mM trehalose and 100 mM trehalose revealed 22 protein bands with molecular weights ranging from 10 kDa to 240 kDa, but lacking the 29 kDa and 42 kDa bands. Proteins with molecular weights of 29 kDa, 130 kDa and 240 kDa were absent in frozen semen supplemented with 100 ng per mL IGF-1 and 150 ng per mL IGF-1.

CONCLUSION

The present study revealed that supplementation of tris basic extender with trehalose at 100 mM and or IGF-1 at 100 ng/mL or 150 ng per mL improves the post-thaw semen characteristics and protects certain fertility related sperm membrane proteins. Doi.org/10.54680/fr23510110612.

Variability in the presentation of complicated jejunal diverticulosis

Jejunal diverticulosis is a rare disease which normally presents for the first time with acute complications, often requiring surgical intervention. The diverticulae are acquired, occurring more commonly after middle age, but their aetiology is unclear. We discuss this condition in the context of four cases which presented to our hospital as emergencies over a five year period: small bowel obstruction, gastrointestinal haemorrhage, small bowel volvulus, and visceral perforation. Our aim is to encourage clinicians to include jejunal diverticular disease as a differential diagnosis in patients with abdominal symptoms.

Risk of adverse pregnancy outcomes prior to the onset of an autoimmune rheumatic disease: a systematic review

OBJECTIVES

An increased risk of adverse maternal and foetal pregnancy complications (including pre-eclampsia, intrauterine growth restriction, and small for gestational age) is well described in women with autoimmune rheumatic disease (ARD) compared with the general population (GenPop). It is less clear, however, whether this risk of adverse pregnancy outcome (APO) also exists in women with 'preclinical ARD' (pre-ARD) before they are diagnosed with an ARD many years post-partum. Therefore, we have undertaken a systematic review of the available evidence on APO in patients who subsequently were diagnosed with a rheumatic disease to identify whether there is an increased risk in pre-ARD.

METHODS

The present study was reported in accordance with the guidance of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) standard. A systematic literature review was performed using the online PubMed database. Pre-SLE and pre-RA patients were defined as those who, over the subsequent years, developed SLE or RA according to international classification criteria.

RESULTS

A total of 176 articles were screened, and 27 original articles were selected for final analysis. Pre-RA was the most studied group, with 15 studies and a total of >1600 pregnancies, and pre-SLE was the second-most studied pre-ARD in pregnancy, with 14 studies and a total of >1000 pregnancies. We found that patients who subsequently developed SLE had an increased burden of poor pregnancy outcomes compared with pregnant women from the GenPop, but fewer APOs compared with pregnancies of women with SLE. In contrast, a similar rate of APOs was found when pre-RA pregnancies were compared with GenPop pregnancies.

CONCLUSION

Our findings of an increased risk of APO in certain pre-ARDs highlights the relevance of taking an obstetric history during the first rheumatology appointment and the need for novel screening strategies for the prediction of APOs. Further research is required to elucidate the immune basis of APOs in preclinical and clinical ARD.

Silent Bowels From a Silent Bite: A Rare Case of Paralytic Ileus Complicating Plasmodium falciparum Infection

Malaria is a life-threatening, parasitic disease that continues to infect millions of people, especially in endemic regions. Despite advancements in malaria treatment, treating the disease remains challenging. One major challenge is identifying the disease from its unconventional manifestations. Therefore, recognizing its unusual clinical presentations is imperative in early detection and management with a better prognosis. This case report highlights the unique finding of paralytic ileus from a patient with confirmed malaria. Further investigation on the concurrence between paralytic ileus and malaria may aid in identifying the disease and subsequent improvement in treatment.

Mechanistic Study of Macranthoside B Effects on Apoptotic Cell Death in Human Cervical Adenocarcinoma Cells

Macranthoside B (MB) is a triterpenoid saponin extracted from Lonicera macranthoides, a traditional Chinese medicine. In the current study, we investigated the anticancer potential of MB in various cancer cells and elucidated its underlying mechanisms. MB exposure inhibited cell proliferation, induced mitochondrial membrane potential (MMP) loss, increased sub-G1 accumulation, and resulted in cleavage of caspase-3 and PARP, which are reflective of apoptosis. In HeLa cells, MB induced down-regulation of SOD2 and GPx1, phosphorylation of Akt and PDK1, and thus promoted ROS-mediated apoptosis. This was further supported by the protection of sub-G1 accumulation, MMP loss, cleavage of caspase-3 and PARP in the presence of N-acetylcysteine (NAC). Additionally, MB induced cell death via down-regulation of ubiquitin-like with PHD and ringfinger domains 1 (UHRF1) and Bcl-xL. Taken together, this study provides a new insight into the apoptosis- inducing potential of MB, and its molecular mechanisms are associated with an increase in oxidative stress and inhibition of the PDK1/Akt pathway.

Comparing pregnancy outcomes in patients with criteria and non-criteria autoimmune disease: A systematic review

BACKGROUND

Not all patients fulfil criteria for specific autoimmune rheumatic diseases (ARDs) and are then defined as having non-criteria (nc)ARD. It is uncertain whether well-recognised associations with adverse pregnancy outcomes in patients with criteria ARD also exist in patients with ncARD or undifferentiated connective tissue disease (UCTD). Therefore, we undertook a systematic review of the prevalence of adverse pregnancy outcomes in various ncARD and UCTD compared with criteria ARD to identify whether there are increased risks and to examine for any benefits of treatment.

METHODS

This study was conducted in accordance with the guidance of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) standard. A systematic literature review was performed using online databases including Medline and PubMed from inception to the beginning of April 2021 using appropriate keywords for various ARD and pregnancy outcomes.

RESULTS

After screening 665 articles, 36 articles were chosen for full text review and 15 selected for final analysis. There were eight studies of nc antiphospholipid syndrome (APS) of more than 7000 pregnancies and seven studies of UCTD of more than 1000 pregnancies. No studies of any other ncARD in pregnancy were identified. We found that patients with either ncAPS or UCTD seem to have an increased burden of poor pregnancy outcomes compared with the general population. Despite the heterogeneity and poor quality of the studies, we also noted that ncAPS and criteria APS patients may have similar rates of obstetric complications with standard and/or non-standard APS treatment regimens.

CONCLUSION

Our findings of increased risks of poor pregnancy outcomes in patients with ncAPS or UCTD will be helpful for pre-pregnancy counselling and management of these patients in pregnancy and support their referral to specialist obstetric-rheumatology and obstetric-haematology clinics.

Achievement of guideline recommended LDL-C goals in patients with acute myocardial infarction (AMI) in Switzerland

Background

In 2016 and subsequently again in 2019 the ESC/EAS Guidelines for the Management of Dyslipidaemia established a more intensive reduction of LDL cholesterol (LDL-C) treatment recommendations. We aim to characterize patients with acute myocardial infarction (AMI) with regards to achievement of recommended LDL-C goals and their current lipid lowering therapy.

Methods

We retrospectively analysed patients with AMI admitted to Swiss hospitals between 2016 and 2020. Patients were classified as “very high risk” due to prior atherosclerotic cardiovascular disease (ACSVD) events including at least one of the following: Myocardial infarction (MI), stroke, peripheral arterial disease (PAD) and type 2 diabetes mellitus with target organ damage. The remaining patients were classified as “other risk”. LDL-C treatment recommendation goals for the “very high risk” population were set to 1.8mmol/L (2016 ESC/EAS Guidelines) or 1.4mmol/L (2019 ESC/EAS Guidelines) and for the “other risk” population to 2.6mmol/L or 1.8mmol/L. To identify differences between the two groups the Mann-Whitney test was used and for differences within a group the Kruskal-Wallis test. In-hospital outcomes were summarised as major adverse cardiac and cerebrovascular events (MACCE).

Results

Among 7114 patients included, 18.4% were categorized as “very high risk” and 81.6% as “other risk” (p<0.001). In general, the “very high risk” patients were older (69.2y vs. 63.6y, p<0.001), more likely to be men (78.8% vs. 75.3%, p=0.007), had poorer in-hospital outcomes (6.0% vs. 3.4%, p<0.001) and were more often on lipid lowering treatment (statin/ezetimibe/combination) (LLT) prior to admission (64.8% vs 14.0%, p<0.001). The overall LDL-C median for the “very high risk” population was significantly lower than for the “other risk” population (2.4mmol/L vs. 3.5mmol/L, p<0.001). In addition, median (IQR) LDL-C increased in the “other risk” group over the years from 3.5mmol/L (2.7; 4.2) in 2016 to 3.7mmol/L (3.1; 4.4) in 2020. In contrast, no change in LDL-C was observed in the patients at higher risk (Fig. 1).

Patients in the “other risk” group were more likely to miss the recommended LDL-C goals (2016 Guidelines: 80.0% vs. 75.4%, 2019 Guidelines: 94.2% vs. 89.1%). Patients without LLT prior to admission had a higher chance of not reaching the recommendations compared to patients with LLT prior to admission (without LLT: 2016: 85.3% vs. 91.0%, 2019: 96.1% vs. 96.6%), (with LLT: 2016: 50.8% vs. 66.8%, 2019: 83.2% vs.85.2%) (Fig. 2).

Conclusion

Median LDL-C levels have tended to increase in recent years in patients with very high CV risk and AMI admitted to Swiss hospitals. Despite existing lipid lowering therapies only few patients met guideline recommended LDL-C goals. Our results indicate that clinical implementation of guidelines remains to be optimised with regards to achievement of LDL-C goals to reduce CV risk and improve outcomes.

Funding Acknowledgement

Type of funding sources: None. Figure 1. LDL-C developmentFigure 2. Recommended LDL-C goal achievement

A Systematic Review of the safety of non-TNF inhibitor biologic and targeted synthetic drugs in rheumatic disease in pregnancy

INTRODUCTION

Despite increasing evidence to support safe use of tumour necrosis factor inhibitors (TNFi) and other biologic disease modifying anti-rheumatic drugs (bDMARDs) during pre-conception/pregnancy, there remains a paucity of evidence regarding the safety and compatibility of other non-TNFi and novel targeted synthetic (ts)DMARDs during pre-conception/pregnancy. Therefore, we conducted a systematic review to determine the compatibility of these drugs in pre-conception, during pregnancy and post-partum period.

METHOD

Databases including; EMBASE, Pubmed (MEDLINE), and Cochrane were searched up to 23rd October 2020 to find relevant peer-reviewed papers, using keywords including; rheumatic disease, pregnancy, conception/pre-conception, lactation/breastfeeding, childhood and vaccination/infection, and commonly prescribed non-TNFi drugs and tsDMARDs.

RESULTS

Our search yielded 1483 papers that were screened independently by two authors, and 109 full-text papers were eligible for final analysis. These studies reported 1291 maternal pregnancies exposed to non-TNFi bDMARDs and tsDMARDs with known outcomes, including 721 live births, 219 spontaneous miscarriages and 27 congenital abnormalities. Paternal exposures in 174 pregnancies had reassuring outcomes. A total of 48 breast-fed infants were exposed to non-TNFi bDMARDs and no adverse events reported upon long-term follow-up. Fifteen infants exposed to bDMARDs received normal vaccination regimes, including live vaccines, and had normal developmental outcomes, without any complications or infections.

CONCLUSION

Overall, the findings are reassuring and do not suggest a cause for any major concerns or an increased risk of adverse pregnancy outcomes for maternal or paternal exposures to non-TNFi bDMARDs or tsDMARDs. There were no major concerns for breastfeeding exposures to non-TNFi bDMARDs.

30-Day postoperative COVID-19 outcomes in 398 patients from regional hospitals utilising a designated COVID-19 minimal surgical site pathway

INTRODUCTION

Postoperative pulmonary complications and mortality rates during the COVID-19 pandemic have been higher than expected, leading to mass cancellation of elective operating in the UK. To minimise this, the Guy's and St Thomas' Hospital NHS Foundation Trust elective surgery hub and the executive team at London Bridge Hospital (LBH) created an elective operating framework at LBH, a COVID-19 minimal site, in which patients self-isolated for two weeks and proceeded with surgery only following a negative preoperative SARS-CoV-2 polymerase chain reaction swab. The aim was to determine the rates of rates of postoperative COVID-19 infection.

METHODS

The collaboration involved three large hospital trusts, covering the geographic area of south-east London. All patients were referred to LBH for elective surgery. Patients were followed up by telephone interview at four weeks postoperatively.

RESULTS

Three hundred and ninety-eight patients from 13 surgical specialties were included in the analysis. The median age was 60 (IQR 29-71) years. Sixty-three per cent (252/398) were female. In total, 78.4% of patients had an American Society of Anesthesiologists grade of 1-2 and the average BMI was 27.2 (IQR 23.7-31.8) kg/m2. Some 83.6% (336/402) were 'major' operations. The rate of COVID-19-related death in our cohort was 0.25% (1/398). Overall, there was a 1.26% (5/398) 30-day postoperative all-cause mortality rate. Seven patients (1.76%) reported COVID-19 symptoms, but none attended the emergency department or were readmitted to hospital as a result.

CONCLUSION

The risk of contracting COVID-19 in our elective operating framework was very low. We demonstrate that high-volume major surgery is safe, even at the peak of the pandemic, if patients are screened appropriately preoperatively.

POS1177 REVAMPING BIOLOGIC THERAPY DURING COVID-19

Background:

The COVID-19 pandemic has caught us all by surprise – from governments to individuals; the medical fraternity being no exception. It has affected all walks of life; with its immense contagiosity, diverse and intriguing pathogenesis and manifestations differing from other viruses. It has indeed left humanity in dark, unchartered waters; particularly in the early months of the pandemic.

Objectives:

This article shares the experience, in a Rheumatology department in a District General Hospital (DGH) in the United Kingdom, of managing patients on Biologic (b) and Targeted Synthetic (ts) DMARDs, in the midst of the COVID-19 Pandemic.

Methods:

All Rheumatology patients at the Princess Alexandra Hospital (PAH) in Harlow newly started on a biologic or targeted synthetic DMARD between 3rd July and 3rd Oct 2020 were identified. These patients had active inflammatory arthritis. Each patient was discussed in a dedicated Multi-Disciplinary Team (MDT) meeting and a consensus on treatment reached in-line with local and National guidelines.

Figure 1.

A slide presented at the Essex Rheumatology Association (ERA) meeting explaining the process adopted at the Rheumatology Department at Harlow during the peak of COVID-19 pandemic with new b/ts DMARD patients.

Results:

Of the 50 patients identified; 39 had Rheumatoid Arthritis, 6 had Ankylosing Spondylitis and 5 had Psoriatic Arthritis. Of these 50 patients, 5 patients decided against treatment during the stage of ‘Enhanced Verbal Consent’. These patients were flaring recurrently and were in regular contact with the department. However, they were afraid to start new Biologic treatment because of the risks of Covid-19. The breakdown of the biologic agents used in the remaining 45 patients were as follows: Adalimumab:11, Rituximab: 10, Etanercept: 9, Tofacitinib: 11, Tocilizumab SC: 3, Tocilizumab IV: 1, Sarilumab: 2, Secukinumab: 1, Infliximab: 1, Baricitinib: 1, Apremilast: 1

Figure 2.

Breakdown of the various b/ts DMARD agents newly started in the 45 patients between 3/7/20 - 3/10/20 at PA Hospital, Harlow, UK

Conclusion:

The over-riding principle that guided the Department during the COVID crisis was: primum non nocere (first, do no harm). The adherence to the Case Based Discussions (CBDs) positively impacted on decision making, ensuring safe initiation of Biologic DMARDs even during the height of the pandemic. This is vital to achieve early disease remission. The MDT meetings comprising Doctors, Specialist Pharmacist and Nurse Specialists ensured prompt risk stratification of individual patients. It gave patients the opportunity to be part of the decision-making - evident in the five of the fifty patients, who opted to defer the start date of their treatments. The choice of the new Biologic agent was based on the latest National COVID-19 guidelines. The agents with the shortest half-life were selected. Moreover, patients for Rituximab were given one pulsed infusion, as opposed to two infusions. Only one of the 45 patients started on a Biologic agent over this period, either was tested positive or had symptoms suggestive of COVID-19.

References:

[1]https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7261974

[2]https://rmdopen.bmj.com/content/6/2/e001314

[3]https://www.nejm.org/doi/full/10.1056/nejmc2009567

[4]https://www.jrheum.org/content/early/2020/05/13/jrheum.200527

[5]https://www.uptodate.com/contents/coronavirus-disease-2019-covid-19-care-of-adult-patients-with-systemic-rheumatic-disease

[6]www.england.nhs.uk/clinical-guide-rheumatology-patients-v1-19-march-2020.pdf

[7]https://www.rheumatology.org.uk/practice-quality/covid-19-guidance

[8]https://www.nice.org.uk/guidance/ng167/chapter/4-Treatment-considerations

[9]https://www.gmc-uk.org/ethical-guidance/ethical-guidance-for-doctors/decision-making-and-consent

Acknowledgements:

We acknowledge the whole Rheumatology Dept at Harlow for their sincere team work during the COVID-19 pandemic – Sabaa Naz (Rheumatology Pharmacist), Mona Kamal Zou (Biologics Nurse Specialist), Lily Robinson (DMARD Nurse Specialist), Mary Surendran (Osteoporosis Nurse Specialist), Janet Bell (Secretary to Dr Ahmed) and Claire Stroud (Secretary to Dr Farrow).

Disclosure of Interests:

None declared.

23 Reaudit and Completing the Audit Cycle of Quality of Informed Consent for Surgery on Neck of Femur Fracture in Royal Stoke University Hospital

Using guidelines highlighted by the British Orthopaedic Association an reaudit was performed within our department to assess the adequacy of informed consent for NOF fractures to complete the audit cycle. 50 patients were included in the Audit and reaudit. Risk was classified as common, less common, rare and ‘other’. The adequacy of informed consent was evaluated by assessing the quality and accuracy of documentation. Infection, bleeding risks, clots and anaesthetic risks were documented in all patients (100%). Areas of improvement were seen in the documentation of neurovascular injuries (98%), pain (90%) and altered wound healing (87%). There was no significant change in the documentation of failure of surgery (83%) and neurovascular injuries (98%). The Poorly documented risk factors from the initial audit were seen to improve which included mortality (70%), prosthetic dislocation (90%) and limb length discrepancy (50%). There has been a significant improvement in the quality of Informed consent in the department and this could be attributed to the installation of ward posters and verbal dissemination of information to junior doctors. Recommendation for interventions would be to present in the next clinical governance meeting and presenting at the new junior doctors’ induction at August.

O53: SO YOU WANT TO BE A ROBOTIC SURGEON? THE EFFECT OF BASELINE PSYCHOMOTOR ABILITY AND VIDEO-GAME EXPERIENCE ON ROBOTIC SURGICAL SKILL: A RANDOMISED CONTROL TRIAL

Introduction

We assessed whether expert mentoring improved the rate of uptake of robotic surgical skill and whether general advanced psychomotor ability (PMA), and specific video-game experience (VGE) had any impact on robotic surgical skill.

Method

Twenty robotically naive medical students were blinded and randomised to two cohorts; control (CC) and intervention (IC). Each student's initial performance on a variety of da Vinci Skills Simulator (dVSSim) exercises was measured and then reassessed following an independent practice (CC) or mentor guided practice session (IC). Outcome metrics were overall score, time to completion, economy of motion and master workspace range. Quantitative, questionnaire data was collected to evaluate the relationship between robotic surgical skill, PMA and VGE. Statistical analysis was performed with SPSS software utilising the independent t-test.

Result

On average, overall score for CC improved by 16.8% compared to 43.3% for the IC (p=0.04). Time to completion improved by 26.2% (CC) vs. 40% (IC), economy of motion by 16.5% vs. 25% and master workspace range by 8% vs. 11%. PMA correlated with better initial performances for all metrics, especially for overall score (p=0.003) and economy of motion (p=0.03). Students with more VGE had overall scores that were on average 20% better than those with little or no experience and this relationship was also seen for economy of motion and master workspace range.

Conclusion

Expert mentoring leads to a greater improvement in performance than independent practice alone. Advanced PMA correlates with greater innate robotic skill, as does VGE, but to a lesser extent.

Take-home message

1) Expert mentoring leads to a greater improvement in performance than independent practice alone. 2) Advanced PMA correlates with greater innate robotic skill, as does VGE, but to a lesser extent.

Systematic review of the use of translated patient-reported outcome measures in cancer trials

BACKGROUND

Patient-reported outcomes (PROs) are used in clinical trials to assess the effectiveness and tolerability of interventions. Inclusion of participants from different ethnic backgrounds is essential for generalisability of cancer trial results. PRO data collection should include appropriately translated patient-reported outcome measures (PROMs) to minimise missing data and sample attrition.

METHODS

Protocols and/or publications from cancer clinical trials using a PRO endpoint and registered on the National Institute for Health Research Portfolio were systematically reviewed for information on recruitment, inclusion of ethnicity data, and use of appropriately translated PROMs. Semi-structured interviews were conducted with key stakeholders to explore barriers and facilitators for optimal PRO trial design, diverse recruitment and reporting, and use of appropriately translated PROMs.

RESULTS

Eighty-four trials met the inclusion criteria, only 14 (17%) (n = 4754) reported ethnic group data, and ethnic group recruitment was low, 611 (13%). Although 8 (57%) studies were multi-centred and multi-national, none reported using translated PROMs, although available for 7 (88%) of the studies. Interviews with 44 international stakeholders identified a number of perceived barriers to ethnically diverse recruitment including diverse participant engagement, relevance of ethnicity to research question, prominence of PROs, and need to minimise investigator burden. Stakeholders had differing opinions on the use of translated PROMs, the impact of trial designs, and recruitment strategies on diverse recruitment. Facilitators of inclusive research were described and examples of good practice identified.

CONCLUSIONS

Greater transparency is required when PROs are used as primary or secondary outcomes in clinical trials. Protocols and publications should demonstrate that recruitment was accessible to diverse populations and facilitated by trial design, recruitment strategies, and appropriate PROM usage. The use of translated PROMs should be made explicit when used in cancer clinical trials.

148 Superovulation and embryo production response in oestrus-synchronized Arunachali yak

The Arunachali breed of yak is reared by the Monpa pastoral community of Arunachal Pradesh in India for their livelihood and nutritional security on highland pastures. In addition to fulfilling the basic needs of highlanders, this animal is associated with poor production potential linked to its inherent reproductive problems, including silent oestrus, seasonality, and inbreeding, making yak rearing a less-profitable venture. In the recent past, efforts have been made to improve reproductive efficiency of Arunachali yak through assisted reproductive techniques. However, a few regimens for superovulation have been tried to date with limited success in terms of superovulatory response and embryo recovery. Therefore, the present study was undertaken to evaluate the efficacy of two different doses and regimes of superovulation: Stimufol (400 and 200µg per animal) and Folligon (1500 and 1000IU per animal) in Arunachali yak. Twenty-four yaks were allotted in 4 groups (of 6 animals each) and subjected to respective superovulation treatment. Thereafter, the treatment response was assessed in terms of expression of oestrus, interval between treatment and oestrus onset, duration of oestrous, number of corpora lutea and embryos recovered, and analysed using two-way statistical analysis between treatment groups. The results (Table 1) showed a significant (P<0.01) variation in onset of oestrus after the treatment, whereas other responses did not differ among the groups. Further, the recovered embryos were categorized as excellent, good, fair, and poor according to cell size, shape, texture, and number of vesicles present in the blastomeres; 58.33, 20.83, 8.33, and 12.5% embryos in these categories were recovered, respectively. The overall embryo recovery rate was 30.77%, ranging from 10.53 to 52.38% in different treatment groups. The numbers of embryos recorded were less than the numbers of CL present, showing the possibility of non-availability of all ovulated oocytes for fertilization in the oviduct due to untrapping by the fimbriae. The effectiveness of treatments depended upon the precision of oestrus detection and the time of ovulation. In our study, the variation in onset of oestrus might be associated with poor expression of behavioural oestrus in the treated animals. Based on the present findings, we conclude that all the treatments are effective in superovulation and embryo recovery. However, the use of Folligon at 1500IU seemed to be comparatively more effective in Arunachali yak. Table 1. Mean (n=6) average of treatment responses in yak following different superovulatory treatment Variable Treatment Stimufol Folligon 400 µg/animal 200 µg/animal 1500 IU/animal 1000 IU/animal Oestrus response (%) 100 100 100 100 Interval between treatment and oestrus onset (h) 17.67±0.56a 20.83±0.79b 21.17±0.79bc 23.67±1.43c Duration of oestrous (h) 30.33±1.09 28.50±0.99 31.50±1.50 28.83±1.25 Corpora lutea (n) 2.83±1.22 3.50±1.18 3.50±0.67 3.17±0.87 Embryo recovered (n) 0.83±0.83 1.00±0.81 1.83±0.98 0.33±0.21 Recovery rate (%) 29.41 28.57 52.38 10.53 a–cMeans within a row with different superscripts differ P<0.05.

A study of fluid dynamics and human physiology factors driving droplet dispersion from a human sneeze

Recent studies have indicated that COVID-19 is an airborne disease, which has driven conservative social distancing and widescale usage of face coverings. Airborne virus transmission occurs through droplets formed during respiratory events (breathing, speaking, coughing, and sneezing) associated with the airflow through a network of nasal and buccal passages. The airflow interacts with saliva/mucus films where droplets are formed and dispersed, creating a route to transmit SARS-CoV-2. Here, we present a series of numerical simulations to investigate droplet dispersion from a sneeze while varying a series of human physiological factors that can be associated with illness, anatomy, stress condition, and sex of an individual. The model measures the transmission risk utilizing an approximated upper respiratory tract geometry for the following variations: (1) the effect of saliva properties and (2) the effect of geometric features within the buccal/nasal passages. These effects relate to natural human physiological responses to illness, stress, and sex of the host as well as features relating to poor dental health. The results find that the resulting exposure levels are highly dependent on the fluid dynamics that can vary depending on several human factors. For example, a sneeze without flow in the nasal passage (consistent with congestion) yields a 300% rise in the droplet content at 1.83 m (≈6 ft) and an increase over 60% on the spray distance 5 s after the sneeze. Alternatively, when the viscosity of the saliva is increased (consistent with the human response to illness), the number of droplets is both fewer and larger, which leads to an estimated 47% reduction in the transmission risk. These findings yield novel insight into variability in the exposure distance and indicate how physiological factors affect transmissibility rates. Such factors may partly relate to how the immune system of a human has evolved to prevent transmission or be an underlying factor driving superspreading events in the COVID-19 pandemic.

ABVD and BEACOPP regimens' effects on fertility in young males with Hodgkin lymphoma

Purpose

Considering the increased cancer patient survivorship, the focus is now on addressing the impacts of treatment on quality of life. In young people, altered reproductive function is a major issue and its effects in young males are largely neglected by novel research. To improve clinician awareness, we systematically reviewed side effects of chemotherapy for Hodgkin lymphoma (HL) in young males.

Methods

The review was prospectively registered (PROSPERO N. CRD42019122868). Three databases (Medline via PUBMED, SCOPUS, and Cochrane Library) were searched for studies featuring males aged 13-51-years who underwent chemotherapy for HL using ABVD (Adriamycin® (doxorubicin), bleomycin, vinblastine, and dacarbazine) or BEACOPP (bleomycin, etoposide, doxorubicin, cyclophosphamide, vincristine, procarbazine, and prednisolone) regimens. These chemotherapy regimens were compared against each other using sperm characteristics, FSH, and inhibin B levels to measure fertility levels.

Results

Data were extracted from five studies featuring 1344 patients. 6 months post-ABVD saw marked deterioration in sperm count, further reduced by more cycles (P = 0.05). Patients treated with BEACOPP rather than ABVD were more prone to oligospermia. Receiving fewer cycles of both regimens increased the likelihood of sperm production recovering. Patients treated with 6-8 cycles of BEACOPP did not recover spermiogenesis.

Conclusions

ABVD and BEACOPP regimens significantly reduce fertility function to varying effects depending on treatment duration. ABVD temporarily causes significant reductions in male fertility, whereas BEACOPP’s effects are more permanent. Therefore, clinicians should discuss fertility preservation with male patients receiving infertility-inducing gonadotoxic therapy. Further high-quality studies are required to more adequality describe the risk to fertility by chemotherapy.

Electronic supplementary material

The online version of this article (10.1007/s12094-020-02483-8) contains supplementary material, which is available to authorized users.

Substantial and sustained reduction in under-5 mortality, diarrhea, and pneumonia in Oshikhandass, Pakistan: evidence from two longitudinal cohort studies 15 years apart

BACKGROUND

Oshikhandass is a rural village in northern Pakistan where a 1989-1991 verbal autopsy study showed that diarrhea and pneumonia were the top causes of under-5 mortality. Intensive surveillance, active community health education and child health interventions were delivered in 1989-1996; here we assess improvements in under-5 mortality, diarrhea, and pneumonia over this period and 15 years later.

METHODS

Two prospective open-cohort studies in Oshikhandass from 1989 to 1996 (Study 1) and 2011-2014 (Study 2) enrolled all children under age 60 months. Study staff trained using WHO guidelines, conducted weekly household surveillance and promoted knowledge on causes and management of diarrhea and pneumonia. Information about household characteristics and socioeconomic status was collected. Hurdle models were constructed to examine putative risk factors for diarrhea and pneumonia.

RESULTS

Against a backdrop of considerable change in the socioeconomic status of the community, under-5 mortality, which declined over the course of Study 1 (from 114.3 to 79.5 deaths/1000 live births (LB) between 1989 and 1996), exceeded Sustainable Development Goal 3 by Study 2 (19.8 deaths/ 1000 LB). Reductions in diarrhea prevalence (20.3 to 2.2 days/ Child Year [CY]), incidence (2.1 to 0.5 episodes/ CY), and number of bloody diarrhea episodes (18.6 to 5.2%) seen during Study 1, were sustained in Study 2. Pneumonia incidence was 0.5 episodes /CY in Study 1 and 0.2/CY in Study 2; only 5% of episodes were categorized as severe or very severe in both studies. While no individual factors predicted a statistically significant difference in diarrhea or pneumonia episodes, the combined effect of water, toilet and housing materials was associated with a significant decrease in diarrhea; higher household income was the most protective factor for pneumonia in Study 1.

CONCLUSIONS

We report a 4-fold decrease in overall childhood mortality, and a 2-fold decrease in childhood morbidity from diarrhea and pneumonia in a remote rural village in Pakistan between 1989 and 2014. We conclude that significant, sustainable improvements in child health may be achieved through improved socioeconomic status and promoting interactions between locally engaged health workers and the community, but that continued efforts are needed to improve health worker training, supervision, and the rational use of medications.

TRIAL REGISTRATION

Not Applicable.

P116 A systematic review of the safety of non-tumour necrosis factor inhibitor and targeted synthetic drugs in rheumatic disease in pregnancy

Background

Despite increasing evidence to support safe use of tumour necrosis factor inhibitor (TNFi) drugs in pregnancy, there remains a paucity of evidence regarding non-TNFi and targeted synthetic disease modifying anti-rheumatic drugs (tsDMARDs) in pregnancy. Therefore, we conducted a systematic review to summarise use of these drugs in pregnancy and breastfeeding.

Methods

Systematic search of databases including; EMBASE, Pubmed (MEDLINE), and Cochrane up to December 2018 using keywords including; commonly prescribed non-TNFi and tsDMARDs, pregnancy, conception/pre-conception, lactation/breastfeeding, childhood and vaccination/infection.

Results

From an initial screen of 700 papers, n = 92 full text papers were included in the final analysis. A summary of findings from known outcomes of pregnancy and breastfeeding exposures as well as long-term follow-up of infants where available are shown in Table 1. Overall, this data does not identify an increased risk of adverse pregnancy outcomes with these drugs in this population of patients.

Conclusion

These findings do not suggest an increased risk of non-TNFi and tsDMARDs in pregnancy. Given that the total number of exposures, however, remain limited these drugs should only be considered in pregnancy if the benefit of maintaining disease control in the mother justifies any potential risk to the fetus. This body of evidence will be useful when counselling women about the potential risks of using these types of drugs during pregnancy and breastfeeding period as well as following accidental exposure to drugs at conception.

Disclosures

H. Nguyen None. K. Ahmed None. J. Flint None. I. Giles None.

Abstract P5-18-08: Defining molecular signatures to personalise management of patients with early breast cancer

Background

A review of breast screening highlighted the need to reduce overdiagnosis. Ductal Carcinoma In-Situ (DCIS) contributes significantly to this overdiagnosis. Epithelial cells in DCIS are as genetically advanced as those in invasive disease, focusing attention on the tumour microenvironment (ME). A key components of the ME in DCIS is the myoepithelial cell(MEC). These cells lie at the interface of the epithelial and stromal compartments, regulating cell function. We previously have identified changes in the MEC that contribute to tumour progression. Here we investigate the functional and clinical significance of a novel change in MEC phenotype: loss of Galectin-7 (Gal-7) expression. Gal-7 is proposed to play a role in apoptosis. We hypothesise that changes in MEC phenotype in DCIS alter the ME towards a pro-invasive phenotype, and hypothesise that loss of Gal-7 modifies the ME, destabilizes the MEC interface and ultimately may lead to loss of the MEC population through apoptosis.

Methods

Gal-7 expression and function was investigated in clinical samples and in-vitro model systems, respectively.

Gal-7 expression was assessed in a series of pure DCIS samples (low risk model) and DCIS with co-existant invasion (high risk model). Tissue sections were stained for Gal-7 and MEC expression scored on a duct-by-duct basis as positive, heterogeneous or negative.

An in-vitro model of normal primary myoepithelial cells isolated from reduction mammoplasty was used to investigate the functional impact of loss of Gal-7. These cells have high endogenous levels of Gal-7. Gal-7 was knocked down using siRNA and apoptosis assessed using cleaved caspase-3. The effect of Gal-7 on MEC layer integrity was assessed using immunofluorescence and adhesion assays.

The global impact of loss of Gal-7 was investigated using RNA sequencing.

Results

In the tissue analysis 1926 DCIS ducts were scored for MEC expression of Gal-7. Significantly more ducts showed loss of Gal-7 in DCIS with co-existant invasion, with pure DCIS showing 388 ducts positive and DCIS with invasion 144 DCIS ducts positive (p=0.0014). Pure DCIS and DCIS with invasion had 99 and 646 negative DCIS ducts respectively (p=0.0002).

In model systems of primary MEC, knockdown of Gal-7 resulted in increased expression of cleaved caspase-3, suggesting lower levels of Gal-7 increases apoptosis. In functional assays silencing Gal-7 reduces adhesion to both fibronectin and laminin extracellular matrices (p-value 0.005 and 0.001 respectively)

RNA sequencing indicates silencing Gal-7 increases LOX expression - a key regulator of the collagen matrix of the microenvironment.

Conclusion

Normal MEC strongly express Gal-7. Expression is lost in DCIS, with significantly more frequent loss in DCIS with co-existant invasion, suggesting that loss is associated with a more advanced phenotype. Functional assays indicate that loss of MEC Gal-7 enhances MEC apoptosis, which may be one mechanism by which this interface is lost during progression. Gal-7 negative MEC also show impaired adhesion to matrix proteins and lead to up-regulation of LOX, an enzyme key in promoting tumourigenesis. The incorporation of Gal-7 expression into a risk stratification algorithm has functional evidence and is currently being investigated.

Citation Format: Allen N, Allen M, Ahmed K, Gomm J, Nelan R, Nagano A, Chelala C, Gadaleta E, Thorat M, Cuzick J, Jones LJ. Defining molecular signatures to personalise management of patients with early 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 P5-18-08.

Outcome of Surgery in Chronic Inactive Mucosal Otitis Media

Chronic otitis media is a common condition seen in patients attending the otorhinolaryngology Department. The discharging ear presents the otologists with the dilemma of operating on it or not. The aim of the this cross-sectional observational study was to find out the outcome of surgery in chronic inactive mucosal otitis media and was conducted on 62 patients of either sex in the age group of 15-60 years in the Department of ENT and Head Neck surgery, Shaheed Suhrawardy Medical College Hospital (ShSMCH), Dhaka, Bangladesh From July 2015 to January 2016. Pre and post operative hearing assessment was done with pure tone audiometry (PTA). Post operative graft status also noted. All the information's were recorded in the fixed protocol. Collected data were classified, edited, coded and entered into the computer for statistical analysis by using updated computerized program SPSS-19. Among 62 cases the mean age were 36.79±10.33 in chronic inactive mucosal otitis media. Majority of the study population were in age group of between 15-25 in this group of which was 16(51.6%). Male were 36(58.06) and 26(41.94) were female. All patients presented with history of otorrhoea in this group, 52(83.87%) had hearing impairment in chronic inactive mucosal otitis media, 30(48.39%) involved in right ear and 26(41.94%) involved in left ear and 06(9.68%) in both ear in chronic inactive mucosal otitis media. Majority of perforation were medium in size in this group of which was 30(48.39%). anterior perforation was 24(38.71%), posterior perforation 28(45.16%) and subtotal 10(16.13%) in chronic inactive mucosal otitis media. Sixty two (100%) cases underwent myringoplasty. Post-auricular approach used in most of operation in this group of which was 60(96.77%). Preoperative air conduction threshold 32(51.61%) were in between 31-45 dB in myringoplasty group (p<0.05) that was statistically significant. Postoperative air conduction threshold 30(48.39%) were between 16-30 dB in myringoplasty group (p<0.05) that was statistically significant. Difference between preoperative and postoperative air conduction threshold mean difference was 11.38 dB and 36.75±5.84 and 25.37±7.46 respectively (p<0.001) in myringoplasty group. Hearing gain was 42(67.74%) in myringoplasty (p>0.05) that was not statistically significant. Graft uptake in myringoplasty was 52(83.9%). Graft failure in myringoplasty was 10(16.1%). post operative complication was tinnitus in 12(19.35%) cases in myringoplasty. Success rate was more in case of posterior perforation than anterior and subtotal perforation in both chronic inactive mucosal otitis media which was 92.86%. Success rate was more in case of medium size perforation than subtotal perforation in chronic inactive mucosal otitis media which was 86.67%. Success rate was (100%) in small perforation in this group. From this study it can be concluded that myringoplasty is a valid treatment modality for chronic inactive mucosal otitis media to achieve an intact tympanic membrane and to gain hearing.

Development and validation of a training and assessment tool for laparoscopic radical nephrectomy

INTRODUCTION

Laparoscopic radical nephrectomy(LRN) is a cornerstone in managing renal cancer and small renal masses. Twenty-first century surgical training faces challenges, thus must be efficient and safe so surgeons attain relevant skills, protecting patients and operative outcomes. This study aimed to systematically develop a tool for training and assessment in LRN and validate the developed tool for use by trainee urologists.

METHODS

This prospective, longitudinal, multi-institutional study was undertaken from September 2014 - June 2015. Healthcare Failure Mode and Effect Analysis was utilised for development and followed by validation where the assessment tool was distributed to five specialists to increase content validity. Four experts were observed as a multi-institutional approach. Hand-assisted, transperitoneal and retroperitoneal approaches were considered.

RESULTS

The LRN Assessment Tool comprised four phases, 17 processes, 41 sub-processes. Four surgeons and operating teams were observed across four hospitals for 19.5hours (5.75h hand-assisted, 8.75h trans-peritoneal, 5h retro-peritoneal). After hazard analysis, three checklists were constructed. Those for hand-assisted LRN and transperitoneal LRN contained four phases, 20 processes, 33 sub-processes and that for retroperitoneal LRN contained four phases, 20 processes, 30 sub-processes. These were merged to form one assessment tool. The final result was a four phase LRN Assessment Tool with 17 processes, 41 sub-processes. All participants agreed the final LRN Assessment Tool included pertinent steps.

CONCLUSIONS

The LRN Assessment Tool was developed using Healthcare Failure Mode and Effect Analysis risk analysis to ensure hazardous procedural sub-steps were included. Validation ascertained important processes were not overlooked. Full application through a pilot study must be undertaken.

An Echocardiographic Study of the Right Ventricular Diastolic Function in Systemic Hypertension and Its Relation with the Left Ventricular Homologous Changes

Diastolic dysfunction is a major predictor of mortality and morbidity in hypertensive patients. Not only LV, the RV is also expected to be affected in this overall procedure. To observe the Echocardiographic changes of diastolic function of the RV in systemic HTN and their relation with similar parameters of the LV was the objective. TDI was used in association with standard Doppler modality. In this cross-sectional study, 50 hypertensive subjects were studied who were devoid of any other conditions that may influence the diastolic function of the RV from 01 May 2012 to 31 October 2012 at Bangabandhu Sheikh Mujib Medical University (BSMMU), Dhaka, Bangladesh. In addition to 2D and M-mode evaluation, standard Doppler and pulsed tissue Doppler assessment of both ventricles were performed. Measurements were obtained for diastolic as well as systolic function of both ventricles. The RV diastolic parameters were impaired in both standard Doppler and tissue Doppler analysis in association with LV parameters. Systolic functions (LV FS and RV TAPSE) were preserved. Doppler-derived tricuspid peak E and E/A were related negatively to septal thickness, but tissue Doppler-derived RV Em/Am showed negative association with both RVAWT and septal thickness. RV RTm was related positively to RVAWT. The RV diastolic parameters showed positive relation with the LV similar parameters both in standard Doppler (E peak velocity, E/A ratio and EDT) and tissue Doppler (Em peak velocity, Em/Am and PCTm) assessment. So, in systemic HTN, LV diastolic dysfunction is also associated with diastolic disturbances of the RV. Pulsed tissue Doppler is a useful tool to detect the changes. RV diastolic parameters correlate well with those of the LV. Prolongation of the active relaxation (RTm) phase of RV is due to its increased wall thickness.

The role of cognitive training in endourology: a randomised controlled trial

INTRODUCTION

Cognitive training is an important training modality which allows the user to rehearse a procedure without physically carrying it out. This has led to recent interests to incorporate cognitive training within surgical education but research is currently limited. The use of cognitive training in surgery is not clear-cut and so this study aimed to determine whether, relative to a control condition, the use of cognitive training improves technical surgical skills on a ureteroscopy simulator, and if so whether one cognitive training method is superior.

METHODS

This prospective, comparative study recruited 59 medical students and randomised them to one of three groups: control- simulation training only (n=20), flashcards cognitive training group (n=20) or mental imagery cognitive training group (n=19). All participants completed three tasks at baseline on the URO Mentor simulator followed by the cognitive intervention if randomised to receive it. Participants then returned to perform an assessment task on the simulator. Outcome measures from the URO Mentor performance report was used for analysis and a quantitative survey was given to all participants to assess usefulness of training received.

RESULTS

This study showed cognitive training to have minimal effects on technical skills of participants. The mental imagery group had fewer laser misfires in the assessment task when compared to both control and flashcards group (P=.017, P=.036, respectively). The flashcards group rated their preparation to be most useful when compared to control (P=.0125). Other parameters analysed between the groups did not reach statistical significance. Cognitive training was found to be feasible and cost effective when carried out in addition to simulation training.

CONCLUSION

This study has shown that the role of cognitive training within acquisition of surgical skills is minimal and that no form of cognitive training was superior to another. Further research needs to be done to evaluate other ways of performing cognitive training.

Clinico-biochemical Profile of Women with Hyperemesis Gravidarum Admitted in a Tertiary Hospital

Hyperemesis gravidarum is the most severe form of nausea and vomiting in pregnancy with poor pregnancy outcome. Hormonal changes, psychological and immunological factors are attributed to the condition. Recently, prevalence of Helicobacter pylori among women with Hyperemesis gravidarum has been revealed. A descriptive, cross-sectional study was carried out at antenatal ward, Department of Obstetrics and Gynaecology, Mymensingh Medical College Hospital, Mymensingh among thirty-six purposively selected patients with Hyperemesis gravidarum to assess the clinic-biochemical profile. Data were collected through interview, physical examinations and laboratory investigations by using case record form. Statistical analyses were performed using SPSS version 20.0 for windows. Highest number 16(44.44%) of respondents were in age group 20 to 24 years with a mean of 23.81±4.55 years. Majority 29(80.56%) of the women had education less than 12 years, as many as 28(77.78%) women were housewives, and at least 14(38.89%) women had unplanned pregnancies. An overwhelming majority 29(80.56%) of women had their pregnancy duration between 8 to 12 weeks. At least 20(55.56%) of women were pregnant for first time, as many as 19(52.78%) women had duration of illness for 5 to 9 weeks, and all the women had remarkable weight loss. Cent per cent women were dehydrated, and appearance of 27(75.00%) women was ill-looking. Thyroid Stimulating Hormone (TSH), total leucocyte count and serum creatinine levels were normal for cent per cent women. As many as 15(41.67%) women had hypokalaemia, while 13(36.11%) had hyponatraemia and 3(8.33%) had hypochloraemia. Patient with Hyperemesis gravidarum often presents with ill-looking appearance, vomiting over 10 times a day, dehydration, remarkable loss of body weight and anaemia. Ketonuria, hyponatraemia, hypokalaemia and hypochloraemia are not associated with severity of illness.