Consensus on a social return on investment model of physical activity and sport: a Delphi study protocol

Background

Physical activity and sport (PAS) have been related to many health outcomes and social benefits. The main aim of this research is to build a Social Return on Investment (SROI) model of PAS based on experts' opinion to clarify the domains of impact and how to measure and value them.

Methods and analysis

A Delphi method will be employed with a systematic review on the SROI framework applied to PAS and initial interviews with experts informing the design of the Delphi survey statements. Three iterative rounds of communication with the expert panel will be carried out. Participants will indicate their level of agreement with each statement on a five-point Likert scale. During the second and third iterative rounds, experts will reappraise the statements and will be provided with a summary of the group responses from the panel. A statement will have reached consensus if ≥70% of the panel agree/strongly agree or disagree/strongly disagree after round 3. Finally, group meetings (3-4 experts) will be conducted to ask about the measurement and valuation methods for each domain.

Discussion

The final goal of this project will result in the design of a toolkit for organizations, professionals, and policymakers on how to measure the social benefits of PAS.

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

BACKGROUND

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

METHODS

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

FINDINGS

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

INTERPRETATION

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

FUNDING

Boehringer Ingelheim and Eli Lilly.

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

BACKGROUND

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

METHODS

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

FINDINGS

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

INTERPRETATION

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

FUNDING

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

Predictors and risk factors for admission to critical care in cervicofacial infections: a Maxillofacial Trainee Research Collaborative (MTReC) study

Cervicofacial infections carry significant morbidity. Patients present on a broad spectrum of severity, with some requiring outpatient management and others admission to higher level care. Recognition of risk factors is helpful in decision making regarding the need for admission to higher level care. Prospective data were captured on 1002 patients in 25 centres across 17 regions of the United Kingdom (UK) by the Maxillofacial Trainee Research Collaborative (MTReC). Patients admitted to critical care were compared with those who received ward-level care. Multivariate and receiver operating characteristic curve analyses were used to identify predictors for critical care admission. Our results show that the best predictor for critical care admission is the presence of three or more features of airway compromise (AUC 0.779), followed by C-reactive protein (CRP) >100 mg/L (OR 2.70; 95% CI 1.59 to 4.58; p < 0.005), submandibular space involvement (OR 3.82; 95% CI 1.870 to 7.81; p = 0.003), white cell count (WCC) >12 × 10⁹/ dl (1.05; 95% CI 1.01 to 1.10; p = 0.03), and positive systemic inflammatory response syndrome criteria (OR 2.78; CI 1.35 to 5.80; p = 0.006). Admission to critical care is multifactorial, however, the presence of three or more features of airway compromise is the best predictor. Awareness of this alongside other key clinical findings in cervicofacial infections may allow for the early recognition of patients who may require escalation to critical care.

Multiple sclerosis and COVID-19: Assessing risk perception, patient behaviors and access to disease-modifying therapies

BACKGROUND

Following the outbreak of COVID-19, global healthcare systems have had to rapidly adapt. People with multiple sclerosis (pwMS) were required to make decisions about their individual risk and consequent work and social behaviors. This study aimed to evaluate risk perception and patterns of shielding behavior amongst pwMS at the onset of the COVID-19 pandemic and the subsequent impact on patients' employment and access to disease modifying therapies (DMTs).

METHODS

Postal surveys were sent to 1690 people within a UK population-based MS cohort during the first wave of the COVID-19 pandemic. Patients were surveyed on: (i) perceived vulnerability to COVID-19; (ii) isolation behavior; (iii) interruption to DMT; (iv) employment status; (v) level of satisfaction with their current working arrangement.

RESULTS

Responses were received from 1000 pwMS. Two thirds of patients reported isolating at home during the first wave of the pandemic. This behavior was associated with increased age (p<0.0001), higher disability (p<0.0001) and use of high-efficacy DMTs (p = 0.02). The majority of patients reported feeling vulnerable (82%) with perceived vulnerability associated with higher EDSS (p<0.0001) and receiving a high-efficacy DMT (p = 0.04). Clinician-defined risk was associated with shielding behavior, with those at high-risk more likely to self-isolate/shield (p<0.0001). Patients on high-efficacy DMTs were more likely to have an interruption to their treatment (50%) during the first wave of the pandemic. Most pwMS experienced a change to their working environment, and most were satisfied with the adjustments.

CONCLUSION

This study highlights the risk perception, social behavioral practices and changes to treatment experienced by pwMS during the first wave of the COVID-19 pandemic in a large, well-described UK cohort. The results may help inform management of pwMS during future pandemic waves.

An evaluation of the effectiveness of a lipid clinic in identifying people with familial hypercholesterolaemia and reducing their risk of cardiovascular disease

Introduction

The NHS Long Term Plan aims to ‘prevent up to 150,000 heart attacks, strokes and dementia cases over the next 10 years’.1 People with Familial Hypercholesterolaemia (FH) are considered to be at high-risk of heart attack, stroke and dementia but an estimated 90% remain undiagnosed.1 The Chesterfield and Dronfield Primary Care Network were commissioned to set-up a 12-month pharmacist-led clinic across 9 practices to identify, treat and refer FH patients. Patients with suspected FH benefit from referral to specialist services.2

Aim

This study aimed to evaluate the number of FH patients identified and any unintended benefits of the Lipid Clinic.

Methods

Ethical approval was not required for this service evaluation. Informed consent was sought prior to data collection and the dataset was anonymised. Searches of practice patient records identified patients with a previously raised lipid level (total Cholesterol &gt;7.5mmol/L and/or non-HDL-C &gt; 5.9mmol/L)2 for review in the Lipid Clinic. Patients reviewed in the Lipid Clinic were initiated/optimised on lipid lowering medication as appropriate.2 Data were collected for patients invited for review in the Lipid Clinic between May-July 2022. Patients’ attendance as well as decline/non-response to the Clinic was recorded. The data collected included family history, QRISK score (where applicable), lipid lowering treatment the patient was taking (if any) and blood tests results (serum lipids, HBA1c and thyroid function tests). If bloods were deranged it was documented whether or not it was a new finding. The data was analysed by categorising patients into potential FH, primary/secondary prevention of cardiovascular disease and whether they needed referral to secondary care.

Results

Out of the 260 patients invited for review, 219 attended the clinic. Of these, 30 (13.7%) were provided with lifestyle advice as they did not meet the criteria for treatment. Twenty-three patients (10.5%) met the Simon-Broom criteria for possible FH. A further 3 patients identified were known to have FH but had not undergone genetic cascade testing. These 26 patients (11.8%) were referred to secondary care for genetic testing and specialist input. Newly raised HbA1c indicative of either diabetes or non-diabetic hyperglycaemia was incidentally found in 39 patients (17.8%). Lipid-lowering medication was initiated/titrated in 189 patients (86.3%).

Discussion/Conclusion

The significant proportion of patients requiring follow up in secondary care (11.8%) suggesting targeted searches are effective in identifying patients with possible FH. Identifying FH patients, testing and treating their family members appropriately reduces their risk of cardiovascular events.2 The Lipid Clinic has identifying that nearly a fifth of patients were previously undiagnosed with either diabetes or non-diabetic hyperglycaemia (17.8%) suggests that this is also an opportunity to identify and treat these patients earlier than they would otherwise have been identified. The results highlight the need for primary care staff education on the new AAC NHS Guidelines2 relating to managing lipid results. One limitation of the study is although the Lipid Clinic has received good informal feedback, formal feedback is yet to be collected from patients and stake holders. In addition, the clinic is still ongoing, and more data is being collected.

References

1. NHS Long Term Plan. Chapter 3: Further progress on care quality and outcomes. Better care for major health conditions. Cardiovascular Disease. 2019. Available from: https://www.longtermplan.nhs.uk/online-version/chapter-3-further-progress-on-care-quality-and-outcomes/better-care-for-major-health-conditions/cardiovascular-disease/

2. Khatib R, Neely D, on behalf of the AAC Clinical Subgroup. Summary of National Guidance for Lipid Management for Primary and Secondary Prevention of CVD, AAC NHS Guidelines, Nov 2021. Review date: Nov 2022. NICE endorsed Dec 2021.

3. National Institution for Health and Care Excellence (NICE). Cardiovascular disease: risk assessment and reduction, including lipid modification, Clinical guideline [CG181] Published: 18 July 2014 Last updated: 27 September 2016.

Incisional hernia following colorectal cancer surgery according to suture technique: Hughes Abdominal Repair Randomized Trial (HART)

BACKGROUND

Incisional hernias cause morbidity and may require further surgery. HART (Hughes Abdominal Repair Trial) assessed the effect of an alternative suture method on the incidence of incisional hernia following colorectal cancer surgery.

METHODS

A pragmatic multicentre single-blind RCT allocated patients undergoing midline incision for colorectal cancer to either Hughes closure (double far-near-near-far sutures of 1 nylon suture at 2-cm intervals along the fascia combined with conventional mass closure) or the surgeon's standard closure. The primary outcome was the incidence of incisional hernia at 1 year assessed by clinical examination. An intention-to-treat analysis was performed.

RESULTS

Between August 2014 and February 2018, 802 patients were randomized to either Hughes closure (401) or the standard mass closure group (401). At 1 year after surgery, 672 patients (83.7 per cent) were included in the primary outcome analysis; 50 of 339 patients (14.8 per cent) in the Hughes group and 57 of 333 (17.1 per cent) in the standard closure group had incisional hernia (OR 0.84, 95 per cent c.i. 0.55 to 1.27; P = 0.402). At 2 years, 78 patients (28.7 per cent) in the Hughes repair group and 84 (31.8 per cent) in the standard closure group had incisional hernia (OR 0.86, 0.59 to 1.25; P = 0.429). Adverse events were similar in the two groups, apart from the rate of surgical-site infection, which was higher in the Hughes group (13.2 versus 7.7 per cent; OR 1.82, 1.14 to 2.91; P = 0.011).

CONCLUSION

The incidence of incisional hernia after colorectal cancer surgery is high. There was no statistical difference in incidence between Hughes closure and mass closure at 1 or 2 years.

REGISTRATION NUMBER

ISRCTN25616490 (http://www.controlled-trials.com).

Evaluation of prognostic risk models for postoperative pulmonary complications in adult patients undergoing major abdominal surgery: a systematic review and international external validation cohort study

BACKGROUND

Stratifying risk of postoperative pulmonary complications after major abdominal surgery allows clinicians to modify risk through targeted interventions and enhanced monitoring. In this study, we aimed to identify and validate prognostic models against a new consensus definition of postoperative pulmonary complications.

METHODS

We did a systematic review and international external validation cohort study. The systematic review was done in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. We searched MEDLINE and Embase on March 1, 2020, for articles published in English that reported on risk prediction models for postoperative pulmonary complications following abdominal surgery. External validation of existing models was done within a prospective international cohort study of adult patients (≥18 years) undergoing major abdominal surgery. Data were collected between Jan 1, 2019, and April 30, 2019, in the UK, Ireland, and Australia. Discriminative ability and prognostic accuracy summary statistics were compared between models for the 30-day postoperative pulmonary complication rate as defined by the Standardised Endpoints in Perioperative Medicine Core Outcome Measures in Perioperative and Anaesthetic Care (StEP-COMPAC). Model performance was compared using the area under the receiver operating characteristic curve (AUROCC).

FINDINGS

In total, we identified 2903 records from our literature search; of which, 2514 (86·6%) unique records were screened, 121 (4·8%) of 2514 full texts were assessed for eligibility, and 29 unique prognostic models were identified. Nine (31·0%) of 29 models had score development reported only, 19 (65·5%) had undergone internal validation, and only four (13·8%) had been externally validated. Data to validate six eligible models were collected in the international external validation cohort study. Data from 11 591 patients were available, with an overall postoperative pulmonary complication rate of 7·8% (n=903). None of the six models showed good discrimination (defined as AUROCC ≥0·70) for identifying postoperative pulmonary complications, with the Assess Respiratory Risk in Surgical Patients in Catalonia score showing the best discrimination (AUROCC 0·700 [95% CI 0·683-0·717]).

INTERPRETATION

In the pre-COVID-19 pandemic data, variability in the risk of pulmonary complications (StEP-COMPAC definition) following major abdominal surgery was poorly described by existing prognostication tools. To improve surgical safety during the COVID-19 pandemic recovery and beyond, novel risk stratification tools are required.

FUNDING

British Journal of Surgery Society.

POS0083-PARE DRIVING IMPROVEMENT IN AXIAL SPONDYLOARTHRITIS SERVICES: THE USE OF QUALITY IMPROVEMENT APPROACHES AND TOOLS

Background

Quality Improvement (QI) methods have been used in healthcare since the late 1980s across a wide range of healthcare settings. However, in the UK they have not been applied widely within rheumatology including axial Spondyloarthritis (axial SpA). In 2017, the UK healthcare regulator, NICE, produced a national clinical guideline for axial SpA, but there was no mechanism to encourage uptake of its recommendations.

The National Axial Spondyloarthritis Society created a programme to use QI approaches to help encourage uptake of the Guidelines and act as a catalyst for wider improvement in axial SpA care.

Objectives

To encourage service improvement in axial Spondyloarthritis care through the use of quality improvement theory and methods.

Methods

In late 2019 six rheumatology departments were selected to participate in the first cohort. The programme design was underpinned by:

• A framework for management grounded in systems theory1

• A learning system that brings healthcare organisations together2

• A set of tools to develop, test and implement changes: the Model for Improvement3.

The teams met four times for training in QI methods, plus team-based online coaching. They had time to develop their projects and networking opportunities to share their data and experiences of implementation.

We conducted a qualitative review of the programme in year one. We interviewed 31 programme participants and reviewed programme documentation.

Results

The review found that:

•A proven QI framework provides a strong basis to build improvement

•A competitive programme helps foster motivation and accountability

•The programme provides the time to use tools to understand the problem and construct improvement aims

•Measurement is key to understand improvement and to create a story of change

•Collaboration and engagement is key within the team and with other stakeholders.

The teams have:

Conclusion

Despite the challenges of posed by the Covid-19 pandemic, a structured QI programme has enabled clinicians to stay engaged and implement projects to reduce diagnostic delay and improve care.

References

[1]Deming WE. The new economics for industry. Government, Education, Massachusetts Institute of Technology, Cambridge, MA. 1993;1:235.

[2]Institute for Healthcare Improvement. The Breakthrough Series: IHI’s Collaborative Model for Achieving Breakthrough Improvement. IHI Innovation Series white paper. Boston: Institute for Healthcare Improvement. 2003.

[3]Langley GJ, Nolan KM, Nolan TW, Norman L, Provost LP. The improvement guide. San Francisco: Jossey–Bass. 1996.

Disclosure of Interests

Dale Webb Grant/research support from: Grant funding from AbbVie, Biogen, Lilly, Janssen, Novartis & UCB, Rosie Barnett: None declared, Lucy Davies: None declared

The paradox-breaking panRAF plus SRC family kinase inhibitor, CCT3833, is effective in mutant KRAS-driven cancers

BACKGROUND

KRAS is mutated in ∼90% of pancreatic ductal adenocarcinomas, ∼35% of colorectal cancers and ∼20% of non-small-cell lung cancers. There has been recent progress in targeting G12CKRAS specifically, but therapeutic options for other mutant forms of KRAS are limited, largely because the complexity of downstream signaling and feedback mechanisms mean that targeting individual pathway components is ineffective.

DESIGN

The protein kinases RAF and SRC are validated therapeutic targets in KRAS-mutant pancreatic ductal adenocarcinomas, colorectal cancers and non-small-cell lung cancers and we show that both must be inhibited to block growth of these cancers. We describe CCT3833, a new drug that inhibits both RAF and SRC, which may be effective in KRAS-mutant cancers.

RESULTS

We show that CCT3833 inhibits RAF and SRC in KRAS-mutant tumors in vitro and in vivo, and that it inhibits tumor growth at well-tolerated doses in mice. CCT3833 has been evaluated in a phase I clinical trial (NCT02437227) and we report here that it significantly prolongs progression-free survival of a patient with a G12VKRAS spindle cell sarcoma who did not respond to a multikinase inhibitor and therefore had limited treatment options.

CONCLUSIONS

New drug CCT3833 elicits significant preclinical therapeutic efficacy in KRAS-mutant colorectal, lung and pancreatic tumor xenografts, demonstrating a treatment option for several areas of unmet clinical need. Based on these preclinical data and the phase I clinical unconfirmed response in a patient with KRAS-mutant spindle cell sarcoma, CCT3833 requires further evaluation in patients with other KRAS-mutant cancers.

Rapid detection and differentiation of mobile colistin resistance (mcr-1 to mcr-10) genes by real-time PCR and melt-curve analysis

BACKGROUND

The emergence of multi-drug-resistant (MDR) micro-organisms prompted new interest in older antibiotics, such as colistin, that had been abandoned previously due to limited efficacy or high toxicity. Over the years, several chromosomal-encoded colistin resistance mechanisms have been described; more recently, 10 plasmid-mediated mobile colistin resistance (mcr) genes have been identified. Spread of these genes among MDR Gram-negative bacteria is a matter of serious concern; therefore, reliable and timely mcr detection is paramount.

AIM

To design and validate a multiplex real-time polymerase chain reaction (PCR) assay for detection and differentiation of mcr genes.

METHODS

All available mcr alleles were downloaded from the National Center for Biotechnology Information Reference Gene Catalogue, aligned with Clustal Omega and primers designed using Primer-BLAST. Real-time PCR monoplexes were optimized and validated using a panel of 120 characterized Gram-negative strains carrying a wide range of resistance genes, often in combination. Melt-curve analysis was used to confirm positive results.

FINDINGS

In-silico analysis enabled the design of a 'screening' assay for detection of mcr-1/2/6, mcr-3, mcr-4, mcr-5, mcr-7, mcr-8 and mcr-9/10, paired with an internal control assay to discount inhibition. A 'supplementary' assay was subsequently designed to differentiate mcr-1, mcr-2, mcr-6, mcr-9 and mcr-10. Expected results were obtained for all strains (100% sensitivity and specificity). Melt-curve analysis showed consistent melting temperature results. Inhibition was not observed.

CONCLUSIONS

The assay is rapid and easy to perform, enabling unequivocal mcr detection and differentiation even when more than one variant is present. Adoption by clinical and veterinary microbiology laboratories would aid the surveillance of mcr genes amongst Gram-negative bacteria.

Coronavirus disease 2019 pandemic: staged management of surgical services for gynecology and obstetrics

The coronavirus disease 2019 pandemic warrants an unprecedented global healthcare response requiring maintenance of existing hospital-based services while simultaneously preparing for high-acuity care for infected and sick individuals. Hospitals must protect patients and the diverse healthcare workforce by conserving personal protective equipment and redeployment of facility resources. While each hospital or health system must evaluate their own capabilities and surge capacity, we present principles of management of surgical services during a health emergency and provide specific guidance to help with decision making. We review the limited evidence from past hospital and community responses to various health emergencies and focus on systematic methods for adjusting surgical services to create capacity, addressing the specific risks of coronavirus disease 2019. Successful strategies for tiered reduction of surgical cases involve multidisciplinary engagement of the entire healthcare system and use of a structured risk-assessment categorization scheme that can be applied across the institution. Our institution developed and operationalized this approach over 3 working days, indicating that immediate implementation is feasible in response to an unforeseen healthcare emergency.

CHARACTERISING POLYPHARMACY IN THE VERY OLD: FINDINGS FROM THE NEWCASTLE 85+ STUDY

Polypharmacy is potentially harmful and under-researched amongst the fastest growing section of society, the very old (85+). This study aimed to characterise polypharmacy using data from the Newcastle 85+ Study – a prospective cohort of people living in north east England who turned 85 in 2006 (n=845). The prevalence of polypharmacy was examined using cut-points of 0, 1, 2-4, 5-9 and ≥10 medicines – so-called ‘no polypharmacy’, ‘monotherapy’, ‘minor polypharmacy’, ‘polypharmacy’ and ‘hyperpolypharmacy.’ Crosstabulations and Upset plots identified the most frequently prescribed medicines and medication combinations within these categories, at age 85. Mixed effects models assessed whether gender and socioeconomic position were associated with prescribing changes over time (age 85.5-90.5 years). Polypharmacy (49.6%) was more common than minor polypharmacy (24.6%) and hyperpolypharmacy (16.0%). Within these categories, cardiovascular, non-opioid analgesic and gastrointestinal medications were most frequently prescribed. Medication combinations were many and varied. Aspirin and statins were most commonly co-prescribed amongst people with minor polypharmacy and polypharmacy. Non-opioid analgesics, statins, aspirin and loop diuretics were most common in hyperpolypharmacy. Medications varied by gender and socioeconomic status. Nitrates and oral anticoagulants were more frequently prescribed for men. Bisphosphonates, analgesics and antidepressants were more common in women. Cardiovascular medications, including loop diuretics, were more frequently prescribed for socioeconomically disadvantaged people (25th centile Index of Multiple Deprivation (IMD)), with tricyclic antidepressants and selective beta-2 agonists more common amongst the least disadvantaged (&gt;75th centile IMD). By highlighting prescribing patterns, this study informs our understanding of how polypharmacy may contribute to adverse outcomes in later life.

Bevacizumab with or after chemotherapy for platinum-resistant recurrent ovarian cancer: exploratory analyses of the AURELIA trial

Background

In the open-label randomized phase III AURELIA trial, adding bevacizumab to chemotherapy for platinum-resistant ovarian cancer (PROC) significantly improved progression-free survival and response rate versus chemotherapy alone, but not overall survival (OS). We explored the effect of bevacizumab use after disease progression (PD) in patients randomized to chemotherapy alone.

Patients and methods

In AURELIA, 361 women with PROC were randomized to chemotherapy alone or with bevacizumab. Patients initially randomized to chemotherapy were offered bevacizumab after PD. Post hoc analyses assessed efficacy and safety in three subgroups: chemotherapy alone, chemotherapy followed by bevacizumab after PD, and chemotherapy plus bevacizumab at randomization.

Results

Of the 182 patients randomized to chemotherapy alone, 72 (40%) received bevacizumab after PD and 110 (60%) never received bevacizumab. There were no significant differences in patient and disease characteristics between these subgroups at baseline or the time of PD. Compared with patients never receiving bevacizumab, the risk of death was significantly reduced in patients receiving bevacizumab either upfront with chemotherapy [hazard ratio (HR) = 0.68, 95% confidence interval (CI) 0.52-0.90] or after PD (HR = 0.60, 95% CI 0.43-0.86). The tolerability of bevacizumab was similar with administration upfront or after PD.

Conclusions

Post-PD bevacizumab use may have confounded OS results in AURELIA. In these exploratory analyses of non-randomized subgroups, bevacizumab use, either with chemotherapy or after PD on chemotherapy alone, improved OS compared with no bevacizumab. Combining bevacizumab with chemotherapy at first appearance of platinum resistance maximises the likelihood of patients receiving this active treatment for PROC. ClinicalTrials.gov: NCT00976911.

The effect of packaging on consumer eating quality of beef

This experiment examined 3 packaging systems: overwrap packaging using oxygen permeable film (OWP); vacuum skin packaging (VSP) and modified atmosphere packaging (MAP, 80%O₂ and 20%CO₂) on consumer sensory. Three primals from 48 carcasses were aged in vacuum packs for 5, 12 or 40 days. Steaks from longissimus lumborum, gluteus medius and psoas major muscles were packed in OWP, VSP and MAP for 9 days. Untrained consumers scored grilled steaks for tenderness, juiciness, liking of flavour and overall acceptability. Steaks in MAP had 10-12 points lower sensory scores (on a 100 point scale) compared to the OWP, or VSP systems (P < 0.001). The packaging effect was independent of days aging and muscle. It was concluded that high oxygen MAP has the potential to be included as an input variable in the Meat Standards Australia beef grading model. This would be contingent upon research into when the MAP effect occurred and the effect of using different gas mixtures on eating quality.

Late-onset Becker-type muscular dystrophy in a Border terrier dog

A 9-year-old Border terrier was presented to a referral hospital after a 1-year history of progressive stiffness and exercise intolerance. Neurological examination was consistent with a neuromuscular disorder. Serum creatine kinase activity was mildly elevated. A myopathy was suspected based on MRI findings and electrophysiological examination. Muscle histopathology was consistent with a severe non-inflammatory myopathy of a dystrophic type. Immunofluorescence and western blotting confirmed a dystrophinopathy with an 80-kDa truncated dystrophin fragment similar to Becker muscular dystrophy in people. To our knowledge, this is the first description of a late-onset Becker-type muscular dystrophy in a dog, and the first description of a dystrophinopathy in a Border terrier. Muscular dystrophy in dogs should not be ruled out based on late onset clinical signs and only mildly elevated creatine kinase.

Incorporating airway examination photography into the electronic record

BACKGROUND

Photography of the airway has been used in research to validate preoperative airway assessment and the likelihood of identifying the difficult-to-mask ventilate and/or intubate patient. Up till now, no study has demonstrated the perceived utility of incorporation of airway photographs into the anesthesia preassessment.

METHODS

The University of Florida Health Presurgical Clinic routinely incorporates three photographs of all adult patients during their preanesthesia visit. The first is a head-on view of the patient opening the mouth widely as part of a Mallampati examination, and the second and third are side views of the patient prognathing and with the neck in maximal extension, respectively. After IRB approval, providers of anesthesia were surveyed regarding their opinions on the perceived value of the new process. Chi-square tests were used to determine if the responses to each question significantly differed from the distribution that would be predicted by chance. P < 0.05 was considered statistically significant.

RESULTS

The survey was emailed to 180 individuals, with 145 responding. The responses significantly (P < 0.0001) indicated that the photographs helped the providers plan care for their patients and improved their satisfaction with the preoperative assessment. Technical and educational barriers were overcome using iterative Plan-Do-Study-Act cycles and coaching, respectively.

CONCLUSIONS

Photographs of the airway assessment can successfully be taken and incorporated into an electronic medical record in a busy presurgical clinic. The pictures provide additional perceived value to the traditional written assessment of a patient's airway examination by someone else.

End-of-life discussions: Who's doing the talking?

PURPOSE

To determine, in a tertiary academic medical center, the reported frequency of end-of-life discussions among nurses and the influence of demographic factors on these discussions.

METHODS

Survey of nurses on frequency of end-of-life discussions in two urban academic medical centers. Chi-square tests were used to separately assess the relationship between age, gender, specialty, and experience with responses to the question, "Do you regularly talk with your patients about end-of-life wishes?"

RESULTS

Overall, more than one-third of respondents reported rarely or never discussing end-of-life wishes with their patients. Only specialty expertise (p<0.001) was statistically significantly associated with discussing end-of-life issues with patients. Over half of nurses specializing in critical care responded that they have these discussion "always" or "most of the time." However, for the specialties of surgery (59%) and anesthesiology (56%), the majority of respondents reported rarely or never having end-of-life discussions with patients.

CONCLUSIONS

In a survey conducted in two tertiary care institutions, more than one-third of nurses from all disciplines responded that they never or almost never discuss end-of-life issues with their patients. Specialty influenced the likelihood of discussing end-of-life issues with patients.

Modelling the effect of hydration on skin conductivity

BACKGROUND

Electrical signals are recorded from and sent into the body via the skin in a number of applications. In practice, skin is often hydrated with liquids having different conductivities so a model was produced in order to determine the relationship between skin impedance and conductivity.

METHODS

A model representing the skin was subjected to a variety of electrical signals. The parts of the model representing the stratum corneum were given different conductivities to represent different levels of hydration.

RESULTS

The overall impedance and conductivity of the cells did not vary at frequencies below 40 kHz. Above 40 kHz, levels of increased conductivity caused the overall impedance to decrease.

CONCLUSION

The variation in impedance with conductivity between 5 and 50 mSm^-1 can be modelled quadratically while variation in impedance with conductivity between 5 and 5000 mSm^-1 can be modelled with a double exponential decay.

Erratum to: 36th International Symposium on Intensive Care and Emergency Medicine: Brussels, Belgium. 15-18 March 2016

[This corrects the article DOI: 10.1186/s13054-016-1208-6.].

Modular emergency general surgery training: A pilot study of a novel programme

Introduction Pan-speciality consensus guidance advocates mandatory emergency general surgery (EGS) training modules for specialist registrars (StRs). This pilot study evaluated the impact of EGS modules aimed at StRs over 1 year. Methods Eleven StRs were allocated a focused 4-week EGS module, in addition to the standard 1:12 on-call duty rota, in a tertiary surgical centre. Primary outcome measures included the number of indicative emergency operations and validated Procedure Based Assessments (PBAs) performed, both during the EGS module and over the training year. Results StRs performed a median of 11 (range 5-15) laparotomies during the EGS module versus 31 (range 9-49) over the whole training year. StRs attended 43.7% of available laparotomies during the module (range 24.1-63.7%). EGS modules provided more than one-third of the total emergency laparotomy experience, and a quarter of the emergency colectomy, appendicectomy and Hartmann's procedure experience. There were no differences in EGS module-related outcomes between junior and senior StRs. Significantly more PBAs related to laparotomy and segmental colectomy were completed during EGS modules than the on-call duty rota, at 32% versus 14% (p<0.001) and 48% versus 22% (p=0.019), respectively. Performance levels were maintained following module completion. Conclusions These findings provide an important baseline when considering future modular EGS training.

Effects of a 'school-based' physical activity intervention on adiposity in adolescents from economically disadvantaged communities: secondary outcomes of the 'Physical Activity 4 Everyone' RCT

BACKGROUND/OBJECTIVES:

Obesity prevention during adolescence is a health priority. The ‘Physical Activity 4 Everyone' (PA4E1) study tested a multi-component physical activity intervention in 10 secondary schools from socio-economically disadvantaged communities. This paper aimed to report the secondary outcomes of the study; to determine whether the intervention impacted on adiposity outcomes (weight, body mass index (BMI), BMI z-score), and whether any effect was moderated by sex, baseline BMI and baseline physical activity level, at 12 and 24 months.

SUBJECTS/METHODS:

A cluster randomised controlled trial was conducted in New South Wales, Australia. The school-based intervention included seven physical activity strategies targeting the following: curriculum (strategies to maximise physical activity in physical education, student physical activity plans, an enhanced school sport programme); school environment (physical activity during school breaks, modification of school policy); and parents and the community (parent engagement, links with community physical activity providers). Students' weight (kg), BMI and BMI z-score, were collected at baseline (Grade 7), 12 and 24 months. Linear Mixed Models were used to assess between-group mean difference from baseline to 12 and 24 months. Exploratory sub-analyses were undertaken according to three moderators of energy balance.

RESULTS:

A total of 1150 students (mean age=12 years) provided outcome data at baseline, 1051 (91%) at 12 months and 985 (86%) at 24 months. At 12 months, there were group-by-time effects for weight (mean difference=–0.90 kg (95% confidence interval (CI)=–1.50, −0.30), P<0.01) and BMI (−0.28 kg m⁻² (−0.50, −0.06), P=0.01) in favour of the intervention group, but not for BMI z-score (−0.05 (−0.11; 0.01), P=0.13). These findings were consistent for weight (−0.62 kg (−1.21, 0.03), P=0.01) and BMI (−0.28 kg m⁻² (−0.49, −0.06), P=0.01) at 24 months, with group-by-time effects also found for BMI z-score (−0.08 (−0.14; −0.02), P=0.02) favouring the intervention group.

CONCLUSION:

The PA4E1 school-based intervention achieved moderate reductions in adiposity among adolescents from socio-economically disadvantaged communities. Multi-component interventions that increase adolescents' engagement in moderate-to-vigorous physical activity (MVPA) may assist in preventing unhealthy weight gain.

Prognostic and predictive effects of primary versus secondary platinum resistance for bevacizumab treatment for platinum-resistant ovarian cancer in the AURELIA trial

BACKGROUND

Progression-free survival (PFS), objective response rate (ORR), and patient-reported outcomes (PROs) were significantly improved by adding bevacizumab to chemotherapy for platinum-resistant ovarian cancer (PROC) in the phase III AURELIA trial. We explored treatment outcomes according to primary platinum resistance (PPR) versus secondary platinum resistance (SPR).

PATIENTS AND METHODS

Patients were categorized as PPR (disease progression <6 months after completing first-line platinum therapy) or SPR (progression ≥6 months after first platinum but <6 months after second). The exploratory Cox and logistic regression analyses correlated PFS, ORR, overall survival (OS), and PROs with the time to development of platinum resistance.

RESULTS

Baseline characteristics were similar in patients with PPR (n = 262; 73%) and SPR (n = 99; 27%), although ascites were more common in the PPR subgroup. In bevacizumab-treated patients (n = 179), SPR was associated with improved PFS (median 10.2 versus 5.6 months in PPR patients; P < 0.001) and OS (median 22.2 versus 13.7 months, respectively; P < 0.001) but not PROs (22% versus 22% with improved abdominal/gastrointestinal symptoms at week 8/9). In multivariate analyses, SPR remained an independent prognostic factor for better PFS [adjusted hazard ratio (HR) 0.41, 95% confidence interval (CI) 0.25-0.67; P < 0.001] and OS (HR 0.49, 95% CI 0.30-0.80; P = 0.005) in bevacizumab-treated patients, but was not statistically significant for either end point in the chemotherapy-alone subgroup. The magnitude of PFS benefit from bevacizumab appeared greater in SPR than PPR patients (HR 0.30 versus 0.55, respectively; interaction P = 0.07) with a similar direction of effect for OS (interaction P = 0.18).

CONCLUSIONS

In bevacizumab-treated patients, PFS and OS were more favorable in SPR than PPR patients with equally improved PROs. The PFS and OS benefit from combining bevacizumab with chemotherapy was more pronounced in SPR than PPR PROC. PPR versus SPR should be a stratification factor in future trials evaluating anti-angiogenic therapy for PROC.