Performance Evaluation of a Miniature and Disposable Endovascular Robotic Device

PURPOSE

The LIBERTY® Robotic System is a miniature, single-use device designed to facilitate remote-controlled navigation to intravascular targets. We aim to evaluate the robot's performance to manipulate a range of microguidewires and microcatheters during percutaneous endovascular procedures.

MATERIALS AND METHODS

Six interventional radiologists performed selective robotic-assisted catheterization of eight pre-determined vascular targets in a pig model. The navigation time from the guiding catheter tip to the target vessel was recorded. Each physician with a clinical experience of 20 years completed a questionnaire to evaluate the ease of use, accuracy, and safety of the robotic operation.

RESULTS

Most of the physicians reached the vascular targets in less than one minute. There was no angiographic evidence of vascular injury such as artery laceration or contusion. All physicians reported consensus about the high performance of the robot.

CONCLUSION

The miniature disposable robot is effective at reaching a range of vessels in a porcine model. Physicians found the device intuitive and easy to operate remotely.

Targeted augmented reality-guided transperineal prostate biopsies study: initial experience

Background

Transperineal biopsy of magnetic resonance imaging (MRI)-detected prostate lesions is now the established technique used in prostate cancer (CaP) diagnostics. Virtual Surgery Intelligence (VSI) Holomedicine by Apoqlar (Hamburg, Germany) is a mixed reality (MR)/augmented reality (AR) software platform that runs on the HoloLens II system (Microsoft, Redford, USA). Multiparametric prostate MRI images were converted into 3D holograms and added into a MR space, enabling visualization of a 3D hologram and image-assisted prostate biopsy.

Objective

The Targeted Augmented Reality-GuidEd Transperineal (TARGET) study investigated the feasibility of performing AR-guided prostate biopsies in a MR framework, using the VSI platform in patients with MRI-detected prostate lesions.

Methods

Ten patients with a clinical suspicion of CaP on MRI (Prostate Imaging-Reporting and Data System, PI-RADS 4/5) were uploaded to the VSI HoloLens system. Two MR/AR-guided prostate biopsies were then acquired using the PrecisionPoint Freehand transperineal biopsy system. Cognitive fusion biopsies were performed as standard of care following the MR/AR-guided prostate biopsies.

Results

All 10 patients successfully underwent MR/AR-guided prostate biopsy after 3D MR images were overlaid on the patient's body. Prostatic tissue was obtained in all MR/AR-guided specimens. Seven patients (70%) had matching histology in both the standard and MR/AR-guided biopsies. The remaining three had ISUP (International Society of Urological Pathology) Grade 2 CaP. There were no immediate complications.

Conclusion

We believe this is a world first. The initial feasibility data from the TARGET study demonstrated that an MR/AR-guided prostate biopsy utilizing the VSI Holomedicine system is a viable option in CaP diagnostics. The next stage in development is to combine AR images with real-time needle insertion and to provide further data to formally appraise the sensitivity and specificity of the technique.

The Incidence of Infection Complicating Snakebites in Tropical Australia: Implications for Clinical Management and Antimicrobial Prophylaxis

Objective

To define the incidence of infection following snakebite in tropical Australia and the resulting implications for the routine prescription of prophylactic antibiotics.

Methods

A retrospective study of all individuals presenting to Cairns Hospital, a tertiary referral hospital in tropical Australia, after a snakebite between December 2013 and October 2020.

Results

There were 732 hospitalisations, 720 (98.4%) patients presented within 8 hours of the snakebite, and 29/732 (4.0%) were envenomated. Envenomated patients were more likely to receive empirical antibiotics than nonenvenomated patients (8/29 (27.6%) versus 14/703 (2.0%), p < 0.001), although this was frequently as a bundle of care for critically ill individuals. Superficial skin infection was diagnosed by clinicians in 6/732 (0.8%) patients during their hospitalisation; infection was diagnosed more commonly in envenomated than in nonenvenomated patients (3/29 (10.3%) versus 3/703 (0.4%), p = 0.001). All 3 envenomated individuals diagnosed with infection were believed to have taipan (genus Oxyuranus) bites. Five (83%) of the six patients diagnosed with infection had received empirical antibiotics at presentation; only 1/710 (0.1%) patients who received no antibiotics developed a (superficial) infection.

Conclusion

Infection is a very uncommon complication of snakebite in tropical Australia. Individuals bitten by snakes in tropical Australia should not routinely receive antibiotic prophylaxis.

Harm due to the use of pressure bandage immobilisation in patients bitten by snakes in Australia

BACKGROUND

Pressure bandage immobilisation has remained the recommended first aid treatment for more than 40 years in Australia. However, whilst it is used in most people bitten by a snake, it is often applied poorly, and patients have been envenomed despite good pressure bandage immobilisation. We report two patients who suffered harm from this procedure.

CASE REPORTS

Two men, a 35-year-old and a 44-year-old, were bitten by snakes. Both had a prompt application of pressure bandage immobilisation, and both reported significant pain requiring opioid analgesia whilst being transferred from remote Australia to Cairns Hospital, Queensland. There were substantial delays (9.5 h and 7.5 h) before the pressure bandage immobilisation was released. As a result, both patients developed severe rhabdomyolysis (33,600 U/L and 16,800 U/L [normal < 171 U/L], respectively); there was no evidence of systemic envenoming. The 35-year-old developed a compartment syndrome that required urgent and repeated surgery. The 44-year-old has ongoing foot paraesthesia two years after the bite.

CONCLUSION

With limited good evidence of benefit, and many issues with its use, I recommend that pressure bandage immobilisation as a first aid measure for snakebite in Australia needs to be re-examined.

Viral predation pressure on coral reefs

BACKGROUND

Predation pressure and herbivory exert cascading effects on coral reef health and stability. However, the extent of these cascading effects can vary considerably across space and time. This variability is likely a result of the complex interactions between coral reefs' biotic and abiotic dimensions. A major biological component that has been poorly integrated into the reefs' trophic studies is the microbial community, despite its role in coral death and bleaching susceptibility. Viruses that infect bacteria can control microbial densities and may positively affect coral health by controlling microbialization. We hypothesize that viral predation of bacteria has analogous effects to the top-down pressure of macroorganisms on the trophic structure and reef health.

RESULTS

Here, we investigated the relationships between live coral cover and viruses, bacteria, benthic algae, fish biomass, and water chemistry in 110 reefs spanning inhabited and uninhabited islands and atolls across the Pacific Ocean. Statistical learning showed that the abundance of turf algae, viruses, and bacteria, in that order, were the variables best predicting the variance in coral cover. While fish biomass was not a strong predictor of coral cover, the relationship between fish and corals became apparent when analyzed in the context of viral predation: high coral cover (> 50%) occurred on reefs with a combination of high predator fish biomass (sum of sharks and piscivores > 200 g m^-2) and high virus-to-bacteria ratios (> 10), an indicator of viral predation pressure. However, these relationships were non-linear, with reefs at the higher and lower ends of the coral cover continuum displaying a narrow combination of abiotic and biotic variables, while reefs at intermediate coral cover showed a wider range of parameter combinations.

CONCLUSIONS

The results presented here support the hypothesis that viral predation of bacteria is associated with high coral cover and, thus, coral health and stability. We propose that combined predation pressures from fishes and viruses control energy fluxes, inhibiting the detrimental accumulation of ecosystem energy in the microbial food web.

Approach to Handling Atypical Field Blood Transfusion Scenarios

Special Operations Forces (SOF) medical personnel have been at the forefront of administering blood products in the austere field medicine environment. These far-forward medical providers regularly treat patients and deliver blood transfusions in some of the world's most extreme environments with minimal resources. A multitude of questions have been raised on this topic based on the unique experiences of senior providers in this field. In this paper, we analyze the available literature and present the recommendations of several experts in transfusion medicine for managing atypical field transfusion scenarios.

A hard-won success - but the work continues

BVA NI Branch senior vice president Mark Little reflects on two years of work to save access to vet medicines in Northern Ireland.

STRETCH: Stinging tree exposures to Cairns Hospital

OBJECTIVES

To evaluate the burden of disease, investigate the treatment and response to treatment caused by exposure to stinging tree plants presenting to Cairns Hospital over a 3-year period. Our secondary aim was to examine the benefit from treating such exposures with topical dilute hydrochloric acid (HCl).

METHODS

A retrospective chart review of all patients presenting to Cairns ED over a 3-year period because of stinging tree exposure. Symptoms, signs, treatment and outcomes were recorded.

RESULTS

There were 48 presentations, all having immediate pain after contact with the stinging tree, with 87% describing the pain as moderate or severe. Nearly all were stung on limbs (96%). There were 13 different treatments prior to presentation. In hospital, 60% needed opioid analgesia and a median oral morphine dose equivalent of 15 mg. Of the 29 receiving HCl nine patients reported good relief or complete relief.

CONCLUSIONS

Stinging tree exposure results in significant presentations to the Cairns ED each year. Pain is immediate and severe and there are no clear first aid or definitive treatment recommendations. Further work is needed to ascertain the best first aid and definitive treatment including a formal trial of dilute HCl.

Coral Reef Arks: An In Situ Mesocosm and Toolkit for Assembling Reef Communities

Coral reefs thrive and provide maximal ecosystem services when they support a multi-level trophic structure and grow in favorable water quality conditions that include high light levels, rapid water flow, and low nutrient levels. Poor water quality and other anthropogenic stressors have caused coral mortality in recent decades, leading to trophic downgrading and the loss of biological complexity on many reefs. Solutions to reverse the causes of trophic downgrading remain elusive, in part because efforts to restore reefs are often attempted in the same diminished conditions that caused coral mortality in the first place. Coral Arks, positively buoyant, midwater structures, are designed to provide improved water quality conditions and supportive cryptic biodiversity for translocated and naturally recruited corals to assemble healthy reef mesocosms for use as long-term research platforms. Autonomous Reef Monitoring Structures (ARMS), passive settlement devices, are used to translocate the cryptic reef biodiversity to the Coral Arks, thereby providing a "boost" to natural recruitment and contributing ecological support to the coral health. We modeled and experimentally tested two designs of Arks to evaluate the drag characteristics of the structures and assess their long-term stability in the midwater based on their response to hydrodynamic forces. We then installed two designs of Arks structures at two Caribbean reef sites and measured several water quality metrics associated with the Arks environment over time. At deployment and 6 months after, the Coral Arks displayed enhanced metrics of reef function, including higher flow, light, and dissolved oxygen, higher survival of translocated corals, and reduced sedimentation and microbialization relative to nearby seafloor sites at the same depth. This method provides researchers with an adaptable, long-term platform for building reef communities where local water quality conditions can be adjusted by altering deployment parameters such as the depth and site.

Differential attainment, socioeconomic factors and surgical training

INTRODUCTION

Differential attainment (DA) is the gap in levels of achievement between different groups; socioeconomic factors are thought to play a significant role in DA. The aim of this study was to review and assess the evidence for DA in early surgical training and to examine the potential influence of socioeconomic status.

METHODS

Data were obtained from the General Medical Council GMC for those taking Membership of the Royal College of Surgeons (MRCS) examinations between 2016 and 2019 and core surgical training annual review of competency progression (ARCP) outcomes between 2017 and 2019. The index of multiple deprivation (IMD) was used as a measure of socioeconomic background. Trainees were then divided into deprivation quintiles (DQ1=most deprived, DQ5=least deprived). MRCS and ARCP outcomes were compared between DQ groups using 95% confidence intervals and chi-square tests.

RESULTS

Those from lower socioeconomic backgrounds had significantly lower overall MRCS pass rates (DQ1=45.5%, DQ2=48.9% vs DQ4=59.6%, DQ5=61.5%, p<0.05) and 1st time pass rates (DQ1&2=46.6% vs DQ4&5=63.5%, p<0.001). Additionally, they had a significantly higher number of attempts required to pass MRCS (DQ 1&2=1.86 vs DQ 4&5=1.54, p<0.01). Those from lower socioeconomic backgrounds had a significantly greater proportion of unsatisfactory ARCP outcomes (DQ1&2=24.4% vs DQ 4&5=14.2%, p<0.05).

CONCLUSIONS

There is clear evidence of the influence of socioeconomic background on DA in early surgical training. However, the reasons for this are likely complex and more work is required to investigate this relationship.

EPIC: an evaluation of the psychological impact of early-phase clinical trials in cancer patients

Background

Anxiety and depression in patients with cancer is associated with decreased quality of life and increased morbidity and mortality. However, these are often overlooked and untreated. Early-phase clinical trials (EPCTs) recruit patients with advanced cancers who frequently lack future treatment options, which may lead to increased anxiety and depression. Despite this, EPCTs do not routinely consider psychological screening for patients.

Patients and methods

This prospective observational study explored levels of anxiety and depression alongside impact of trial participation in the context of EPCTs. The Hospital Anxiety and Depression Scale and the Brief Illness Perceptions Questionnaire were completed at the point of EPCT consent, the end of screening and at pre-specified time points thereafter.

Results

Sixty-four patients (median age 56 years; median Eastern Cooperative Oncology Group performance status 1) were recruited. At consent, 57 patients returned questionnaires; 39% reported clinically relevant levels of anxiety whilst 18% reported clinically relevant levels of depression. Sixty-three percent of patients experiencing psychological distress had never previously reported this. Males were more likely to be depressed (P = 0.037) and females were more likely to be anxious (P = 0.011). Changes in anxiety or depression were observed after trial enrolment on an individual level, but not significant on a population level.

Conclusions

Patients on EPCTs are at an increased risk of anxiety and depression but may not seek relevant support. Sites offering EPCTs should consider including psychological screening to encourage a more holistic approach to cancer care and consider the sex of individuals when tailoring psychological support to meet specific needs.

•

Early-phase cancer trial patients have an increased risk of anxiety and depression.

•

Patients at risk were not seeking support for anxiety and depression.

•

Male patients were more likely to be depressed; female patients were more likely to be anxious.

•

This work highlights the need to screen for psychological symptoms in patients entering early-phase trials.

Use of clonidine in the treatment of Irukandji syndrome: A 4-year retrospective cohort study on safety, efficacy and clinical utility

OBJECTIVE

Irukandji syndrome (IS) is an extremely painful condition that causes a significant catecholamine surge and sympathetic autonomic response related to the envenomation from certain types of jellyfish. Current management involves intravenous fluids, magnesium sulphate and large doses of opioids for symptom control. Clonidine, a centrally acting alpha-2 agonist, is often used as an analgesic adjunct to reduce opioid requirements in acute pain. The present study explores the safety and efficacy of clonidine in reducing opioid requirements in IS.

METHODS

All patients diagnosed with IS at Cairns Hospital between 1 March 2016 and 30 April 2020, and participants from the Magnesium in Irukandji Study Trial, were included in this retrospective study (n = 114). Cases were separated into two groups depending on whether or not they received clonidine, and subsequently analysed according to pre- and post-intervention opioid requirements, clonidine dose administered and adverse effects.

RESULTS

Notably, 39 patients with IS received ≥1 mcg/kg clonidine and the remaining 75 did not. There was no difference in oral morphine equivalent daily dose (oMEDD) between groups before clonidine administration; however, there was a significant reduction in oMEDD required after patients received clonidine (26.1 mg; 95% CI 4.6-47.7) compared with those who did not (66.6 mg; 95% CI 56.9-86.1) (F = 8.722, df = 1 × 224, P = 0.003). One episode of hypotension occurred following the intervention.

CONCLUSION

Patients with IS who received clonidine required significantly lower opioid requirements than those who did not receive clonidine. Clonidine was safe to administer and should be considered early when treating IS. The optimal clonidine dose remains unclear and requires prospective studies to validate our findings.

MO214: Health-Related Quality of Life Among Patients With Anca Vasculitis

BACKGROUND AND AIMS

Anti-neutrophil cytoplasmic antibody-associated vasculitis (AAV) is a debilitating disease that can have a significant impact on a patient's quality of life. The aim of this study was to assess the longitudinal quality of life amongst those diagnosed with AAV using the EQ-5D instrument, which allows for calculation of quality-adjusted life years (QALYs.)

METHOD

A total of 343 patients with AAV participated in this study, of which 191 (55.7%) were male, resulting in 2746 episodes. The EQ-5D-5L standardised instrument was used to evaluate health-related quality of life in the domains of mobility, self-care, usual activities, pain/discomfort, anxiety/depression and to generate a summary index score. Overall health was also rated using a visual analogue scale (0–100). EQ-5D questionnaires were completed during routine nephrology clinic attendances and through a vasculitis patient support smartphone app. We used a random effects model to control for multiple entries relating to individual patients.

RESULTS

A lower quality of life was seen amongst those with AAV (median index value 0.80, overall population average 0.856). The mean visual analogue scale score was 75.6 ± 17.3 (overall population average 82.8, Fig. 1). Patients’ pain and discomfort level (mean 1.95) was most affected while self-care (mean 1.33) was least affected (Fig. 1). An increase in BVAS tightly correlated with a reduction in quality of life. Using the random effects model, the index score was seen to decrease with increasing age with a 2.7% reduction in index score per decade. A 7% reduction in index score was seen during periods of disease activity compared with periods of remission. Patients with end-stage kidney disease requiring dialysis had an 8% reduction in index score. A reduced quality of life was seen following COVID-19 lockdown with a 5% reduction in index score seen. Using a median survival rate of 6.16 years for patients with small vessel vasculitis, we calculated the QALYs for this population as 4.9 years.

CONCLUSION

We have defined for the first time the EQ-5D index value over the full disease course in patients with AAV. Notably, we have identified a reduction in quality of life during periods of disease activity. Other studies have demonstrated a reduction in quality of life during active disease using the AAV–PRO questionnaire and the Medical Outcomes Study Short Form-36. A decrease in work productivity has also been noted. Previously reported mean index values of 0.72 and 0.76 were lower than our observed values, although both are significantly reduced compared with population norms. In conclusion, this research highlights the negative impact of AAV on patients’ lives.

Study protocol for the St James's Hospital, Tallaght University Hospital, Trinity College Dublin Allied Researchers' (STTAR) Bioresource for COVID-19

Background: The current coronavirus disease 2019 (COVID-19) pandemic began in Ireland with the first confirmed positive case in March 2020. In the early stages of the pandemic clinicians and researchers in two affiliated Dublin hospitals identified the need for a COVID-19 biobanking initiative to support and enhance research into the disease. Through large scale analysis of clinical, regional, and genetic characteristics of COVID-19 patients, biobanks have helped identify, and so protect, at risk patient groups The STTAR Bioresource has been created to collect and store data and linked biological samples from patients with SARS-CoV-2 infection and healthy and disease controls. Aim: The primary objective of this study is to build a biobank, to understand the clinical characteristics and natural history of COVID-19 infection with the long-term goal of research into improved disease understanding, diagnostic tests and treatments. Methods: This is a prospective dual-site cohort study across two tertiary acute university teaching hospitals. Patients are recruited from inpatient wards or outpatient clinics. Patients with confirmed COVID-19 infection as well as healthy and specific disease control groups are recruited.  Biological samples are collected and a case report form detailing demographic and medical background is entered into the bespoke secure online Dendrite database. Impact: The results of this study will be used to inform national and international strategy on health service provision and disease management related to COVID-19. In common with other biobanks, study end points  evolve over time as new research questions emerge. They currently include patient survival, occurrence of severe complications of the disease or its therapy, occurrence of persistent symptoms following recovery from the acute illness and vaccine responses.

369 The Burnout Pandemic; the Effect of Socioeconomic Status and Training Programmes on Burnout in Postgraduate Trainees in the United Kingdom

Introduction

Burnout is described as a state of mental exhaustion caused by one’s professional life, and is characterised by three domains: emotional exhaustion, depersonalisation, and a reduced sense of accomplishment. The prevalence of stress is high amongst doctors, and varies by specialty, gender, trainee level, and socioeconomic status. The authors set out to examine the scale of the problem, as well as to determine the influence of both socioeconomic status and chosen training programme on burnout amongst postgraduate trainees. This would identify at risk groups, and aid in future targeted interventions.

Method

Cross-sectional data was obtained, following approval from the General Medical Council (GMC), from The National Training Survey, completed annually by all trainees in the United Kingdom. Data was then anonymised and analysed. Burnout scores were derived from the Copenhagen Burnout Inventory and are positively framed (higher scores equal lower burnout).

Results

The questionnaire was completed by 63,122 participants across 2019 and 2020. Mean burnout amongst all trainees combined was 52.40 +/- 19.29. Burnout scores from the most deprived quintile was significantly lower compared with those from the least deprived quintile; 51.02 +/- 20.64 versus 52.89 +/- 18.92 respectively (p &lt; 0.001). The highest levels of burnout were reported in Internal Medical Training, Emergency Medicine, Obstetrics and Gynaecology, and Core Surgical Training respectively.

Conclusions

Postgraduates from lower socioeconomic backgrounds are more likely to encounter burnout during training. At risk groups who may also benefit from targeted intervention include Core Surgical Trainees, requiring further examination through future studies.

Case Report: Rotational Thromboelastometry in Taipan Envenomation

Venom-induced consumption coagulopathy (VICC) is one of the most dangerous syndromes caused by snake envenomation and can be caused by several snake species worldwide, including the Australian coastal taipan. Rotational thromboelastometry (ROTEM) provides real-time point-of-care information on all stages of clot formation; however, it has yet to be formally evaluated in the assessment of VICC. We report three cases of Taipan envenomation causing VICC and the associated ROTEM results. The implications for future use of ROTEM in the assessment, management, and further research of VICC are discussed.

Perineal reconstruction supplemented by abdominal advancement following recurrent penile cancer: Two cases

Reconstruction after excision of locoregionally recurrent penile cancer can be a surgical challenge. In this short study, we present two cases of perineal reconstruction using bilateral gracilis flaps supplemented by abdominal advancement for salvage of recurrent penile cancer, reviewing relevant literature and outlining our local approach to the perineum.

MO245OUTCOME OF DIFFERENT INDUCTION REGIMENS IN ANCA-ASSOCIATED GLOMERULONEPHRITIS ACCORDING TO THE HISTOPATHOLOGICAL CHARACTERISTICS: THE REASSESS STUDY*

Background and Aims

Renal involvement in ANCA-associated vasculitis (AAV) impacts significantly on patients’ prognosis. The role of different induction regimens on remission rates and long-term renal outcomes according to renal histological characteristics has not been explored yet.

Method

AAV patients with biopsy-proven renal involvement were collected retrospectively from eleven centers and stratified according to the induction regimen employed: Rituximab (RTX), Cyclophosphamide (CYC) or both (RTX-CYC). Kidney biopsies were classified according to the Berden and Brix classifications.

Renal remission rate was assessed 6 months after the induction regimen and defined as a renal Birmingham Vasculitis Activity Score (BVAS) of 0.

Among patients who achieved remission at 6 months, renal relapse was defined as a renal-BVAS&gt;0 associated with an increase in immunosuppressive treatment.

ESRD was defined as an eGFR&lt;15 ml/min/1,73m2, need for dialysis or renal transplant.

Results

323 patients were identified and followed-up for a median time of 36 months (IQR 18-72). The cohort included 38% patients with GPA and 62% with MPA, 53% patients were MPO-ANCA and 41% PR3-ANCA positive. The median baseline eGFR in the overall cohort was 19 ml/min/1,73m2 (IQR 12- 34). 58% of patients were treated with CYC, 24% with RTX-CYC and 18% with RTX.

According to the Berden classification, 24% biopsies were classified as Focal, 31% as Crescentic, 33% as Mixed and 12% as Sclerotic. The Brix score was assessable in 270/323 (84%) patients: 17%, 52% and 31% were respectively in the Low, Medium and High-risk class.

The overall renal remission at 6 months was 90%; according to the Berden classification, 94% patients achieved remission in the Focal, 88% in the Crescentic, 91% in the Mixed and 86% in the Sclerotic class. According to the Brix risk score, 88% patients achieved remission in the High risk, 91% in the Medium and 96% in the Low-risk class. According to induction regimen employed, 91%, 90% and 90% patients achieved remission in the RTX, CYC and RTX plus CYC group respectively.

In a logistic regression model adjusted for sex, age, ANCA type, AAV diagnosis, creatinine and proteinuria at onset, the induction regimen employed was not predictive of renal remission at 6 months, neither in Berden Focal plus Crescentic and Mixed plus Sclerotic classes, nor in Brix High and Low plus Medium risk classes.

Of the 185 patients with at least 6 months of follow-up available after remission, 25% experienced a renal relapse. In a Cox regression model adjusted for sex, age, ANCA type, AAV diagnosis, creatinine and proteinuria at onset, the induction regimen or histological score were not predictive of renal relapse. In the unadjusted survival analysis with the Kaplan-Maier curve, patients in the Crescentic group treated with RTX had a shorter ESRD-free survival compared to the CYC group (p=0.033) and the RTX-CYC group (p=0.044); figure 1:

This was confirmed also with a Cox regression analysis adjusted for sex, age, ANCA type, AAV diagnosis, creatinine and proteinuria when comparing the RTX group with the CYC one (HR 8.30 [95% CI 1.64 to 42.01], p=0.011); figure 2:

While the eGFR changes over time in the Focal plus Crescentic and Mixed plus Sclerotic classes showed a similar trend between treatment groups, in the Crescentic class the median eGFR values in the RTX group tended to be lower compared to the CYC and the RTX-CYC ones; figure 3:

The rate of severe infections in the RTX, CYC and RTX-CYC group was respectively 6.3, 8.5 and 8.8 per 100 patient-years during the first 12 months.

Conclusion

in a retrospective multicenter survey, response rates and relapse risk after different induction regimens in AAV patients with renal involvement were comparable in the overall cohort and in the different histopathological subgroups.

Although in a small subset of patients, the ESRD-free survival in the Crescentic class was shorter in the RTX group compared to the CYC one.

FC 039RENAL OUTCOME AFTER RITUXIMAB IN ADULT-ONSET IGA VASCULITIS AND CRESCENTIC IGA NEPHROPATHY: A MULTICENTRE STUDY

Background and Aims

Glucocorticoids (GC) and/or immunosuppressive agents are the mainstay of therapy for adult-onset IgA Vasculitis (IgAV), but their efficacy is often partial while their toxicity is relevant. Recently, rituximab (RTX) has been reported as a safe and effective option but only few data on renal outcome are available.1 RTX has also been used in a few cases of crescentic IgA Nephropathy (cIgAN), an IgAN subset with vasculitic lesions and poor response to conventional immunosuppressive regimens.2 We present the results of a multicentre cohort of patients with IgAV and cIgAN treated with RTX.

Method

The databases of 16 consorted European centres were investigated to screen for patients with adult-onset, biopsy-proven IgAV and cIgAN (crescents in ≥25% glomeruli and rapid eGFR worsening at presentation), who received RTX as induction therapy. We selected patients with active renal manifestations at the time of RTX. Remission was defined as a Birmingham Vasculitis Activity Score (BVAS)=0 or &lt;5 if it was due to persistent proteinuria and relapse as an increase in BVAS requiring change in immunosuppressive therapy.

Results

We identified 38 patients with IgAV and 12 patients with cIgAN who received RTX and had active renal involvement at the time of treatment. The median age at onset was 40 years (interquartile range, IQR, 25-53) and more than two-thirds of patients were male (Table 1). The median follow-up after RTX was 41 months (IQR 18-60).

Renal outcomes are reported in Table 2. At the time of treatment, 24 patients (48%) had eGFR ≥60 mL/min/1.73 m2. All had IgAV and their median BVAS was 17 (IQR 10-22). Furthermore, all had microhaematuria and proteinuria. Renal histology showed mesangial or focal endocapillary proliferation in 12/17 (71%) patients who underwent biopsy (class II-IIIA according to Pillebout3). Twenty patients (83%) achieved remission; after a median of 12 months (range 9-14), four experienced a minor relapse and one had a major relapse with significant renal disease progression. Renal function remained stable in all but two patients who developed end-stage renal disease (ESRD). Micro-haematuria subsided in 14/24 (58%) and median 24h proteinuria decreased from 1750 mg (IQR 865-3275) to 175 mg (IQR 100-800) at last follow-up (p=0.029).

Of the 26 patients with eGFR &lt;60 mL/min/1.73 m2, 14 had IgAV and 12 had cIgAN. All were biopsied and 20 (77%) had diffuse endo/extra-capillary proliferation (classes IIIB-IV). Five patients required dialysis but recovered soon after treatment start. Remission was achieved by 16/26 (61%); eight (50%) subsequently relapsed and two (12%) reached ESRD. At last follow-up, eGFR was ≥60 mL/min/1.73 m2 in 8/26 (31%), 10/26 (48%) had stable renal function as compared to the time of RTX, while 8/26 (31%) had developed ESRD. Median 24h proteinuria decreased from 3400 mg (IQR 2150-6500) to 770 mg (177-1315) (p=0.016).

Remission rate and ESRD-free survival were respectively 86% and 92% in patients with IgAV, while they were respectively 42% and 42% in cIgAN patients. Furthermore, 21/24 (87%) patients who received RTX alone or combined to glucocorticoids but not to immunosuppressive agents achieved remission and 22/24 (92%) were ESRD-free at last follow-up. Of the 26 patients receiving immunosuppressive agents, 17 (65%) obtained remission and 18 (69%) were ESRD-free at last assessment. Over the whole follow-up, only one patient reported a severe adverse effect related to RTX (pneumonia).

Conclusion

Renal involvement in adult-onset IgAV and cIgAN is frequently severe. RTX, combined or not with other immunosuppressive agents, may improve renal manifestations and is well tolerated. IgAV patients show higher remission rates and a longer ESRD-free survival as compared to cIgAN patients.

602 Specialty Training Progression from Core Surgical Training: Is There Evidence from Plastic Surgery of The Importance of Location, Location, Location?

Introduction

Obtaining a National Training Number (NTN) in Plastic Surgery is highly competitive (&lt;40 posts per year), with applicant:post ratios between 3.73 to 4.19 in 2017-2019.

Our aim was to compare deaneries for numbers successfully progressing directly from CT2 into a ST3 post in Plastic Surgery.

Method

Data for surgical trainees progressing directly from CT2 to ST3 (2017-2019) in all specialties was obtained from the GMC. The percentage of those directly progressing that obtained a Plastic Surgery NTN and the total number progressing was calculated.

Results

A total of 840 trainees obtained a NTN directly from CT2 between 2017 and 2019, 61 of whom did so in plastic surgery. Of those directly progressing, there was no significant difference between deaneries for the percentage of plastic surgery posts obtained. The highest number of trainees progressed from London deaneries (16 total (26%); 7 South, 6 NC&E, 3 NW) and the lowest number from Yorkshire and Humber (1).

Conclusions

Higher numbers of those undertaking core surgical training in London progress directly from CT2 to ST3 in Plastic Surgery. Low total numbers highlight the competitive nature of obtaining a Plastic Surgery NTN, necessitating many to undertake additional experience prior to obtaining a training number.

354 Differential Attainment in Surgical Training

Introduction

Differential attainment (DA), according to the General Medical Council (GMC), is the gap between attainment levels in different groups. Attainment measures should cover aspects that include academic performance and career progression. Two such areas in surgical training are the MRCS examinations and ARCPs, both of which are required for progression in a career in surgery.

Our aim was to investigation whether socio-economic background was a significant factor for progression in surgical training.

Method

Data from the GMC for Core Surgical Trainees (CSTs) taking the MRCS examination between 2016 and 2019 and CST ARCP outcomes between 2017 and 2019 were obtained. Socio-economic background was assessed using the Index of Multiple Deprivation (IMD). ARCP and MRCS outcomes were assessed against IMD.

Results

Trainees from IMD Q1&2 (most deprived) had a significantly higher (p &lt; 0.01) mean number of attempts (1.86) to pass MRCS examinations than trainees from IMD Q4&5 (least deprived) (1.54). IMD Q1&2 were significantly more likely to obtain unsatisfactory outcomes (24.4%) than trainees from IMD Q4&5 (14.2%) (p &lt; 0.05).

Conclusions

There is clear evidence that differential attainment exists within Core Surgical Training. The reasons for this are likely to be complex and more work is needed to further investigate the relationship.

Swabbing the Urban Environment - A Pipeline for Sampling and Detection of SARS-CoV-2 From Environmental Reservoirs

To control community transmission of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) during the 2020 global pandemic, most countries implemented strategies based on direct human testing, face covering, and surface disinfection. Under the assumption that the main route of transmission includes aerosols and respiratory droplets, efforts to detect SARS-CoV-2 in fomites have focused on locations suspected of high prevalence (e.g., hospital wards, cruise ships, and mass transportation systems). To investigate the presence of SARS-CoV-2 on surfaces in the urban environment that are rarely cleaned and seldomly disinfected, 350 citizens were enlisted from the greater San Diego County. In total, these citizen scientists collected 4,080 samples. An online platform was developed to monitor sampling kit delivery and pickup, as well as to collect sample data. The sampling kits were mostly built from supplies available in pandemic-stressed stores. Samples were processed using reagents that were easy to access despite the recurrent supply shortage. The methods used were highly sensitive and resistant to inhibitors that are commonly present in environmental samples. The proposed experimental design and processing methods were successful at engaging numerous citizen scientists who effectively gathered samples from diverse surface areas. The workflow and methods described here are relevant to survey the urban environment for other viruses, which are of public health concern and pose a threat for future pandemics.

Highly Deformed o-Carborane Functionalised Non-linear Polycyclic Aromatics with Exceptionally Long C-C Bonds

The effect of substituting o-carborane into the most sterically hindered positions of phenanthrene and benzo(k)tetraphene is reported. Synthesised via a Bull-Hutchings-Quayle benzannulation, the crystal structures of these non-linear acenes exhibited the highest aromatic deformation parameters observed for any reported carborane compound to date, and among the largest carboranyl C-C bond length of all organo-substituted o-carboranes. Photoluminescence studies of these compounds demonstrated efficient intramolecular charge-transfer, leading to aggregation induced emission properties. Additionally, an unusual low-energy excimer was observed for the phenanthryl compound. These are two new members of the family of carborane-functionalised non-linear acenes, notable for their peculiar structures and multi-luminescent properties.

Differences in Cardiac Effects of Venoms from Tentacles and the Bell of Live Carukia barnesi: Using Non-Invasive Pulse Wave Doppler

Carukia barnesi was the first in an expanding list of cubozoan jellyfish whose sting was identified as causing Irukandji syndrome. Nematocysts present on both the bell and tentacles are known to produce localised stings, though their individual roles in Irukandji syndrome have remained speculative. This research examines differences through venom profiling and pulse wave Doppler in a murine model. The latter demonstrates marked measurable differences in cardiac parameters. The venom from tentacles (CBV_t) resulted in cardiac decompensation and death in all mice at a mean of 40 min (95% CL: ± 11 min), whereas the venom from the bell (CBV_b) did not produce any cardiac dysfunction nor death in mice at 60 min post-exposure. This difference is pronounced, and we propose that bell exposure is unlikely to be causative in severe Irukandji syndrome. To date, all previously published cubozoan venom research utilised parenterally administered venom in their animal models, with many acknowledging their questionable applicability to real-world envenomation. Our model used live cubozoans on anaesthetised mice to simulate normal envenomation mechanics and actual expressed venoms. Consequently, we provide validity to the parenteral methodology used by previous cubozoan venom research.

Orthognathic returns to theatre

The objectives of this retrospective study were to determine the unexpected return-to-theatre rate for orthognathic surgery at James Cook University Hospital and describe the reasons for return. A total of 357 consecutive orthognathic cases under two consultants over a 13-year period were included. Patients who had an unexpected return to theatre were identified and their notes analysed for data including preoperative dentofacial discrepancy, surgical movement, and reason for return. Returns to theatre for the removal of plates and planned procedures such as removal of a distractor or delayed genioplasty, were excluded. Thirteen patients required reoperation (3.6%). The commonest reason for return was malocclusion, and the majority returned within four weeks of the initial procedure. Proportionally more men returned to theatre than women, and revision was more likely to involve the mandible than the maxilla.

Non-invasive assessment of the cardiac effects of Chironex fleckeri and Carukia barnesi venoms in mice, using pulse wave doppler

Both Chironex fleckeri venom (CFV) and Carukia barnesi venoms (CBV) are known to cause significant cardiac morbidity and mortality. Many animal studies have demonstrated cardiac dysfunction with these venoms. This study specifically examines the systolic and diastolic cardiac functions using non-invasive pulse wave doppler. Mitral and aortic doppler sonograms of anaesthetised mice were obtained utilising a 10 MHz doppler probe. These continuous sonograms were analysed to ascertain changes in cardiac function before and after the parenteral administration of the test venoms. We found that CFV administration causes rapid cardiac dysfunction without a change in heart rate. Analysis of the resulting sonograms shows both systolic and diastolic dysfunction which together is suggestive of a progressively poorly compliant, contracted left ventricle. Additionally, the rapidity of cardiac dysfunction suggests a direct effect of CFV on myocardial cells. In contrast CBV showed a moderate immediate inotropic and chronotropic effect that was sustained until precipitous cardiac decompensation. This is consistent with the hypotheses of a toxin induced stress cardiomyopathy from sustained catecholaminergic activity.

A multiomic analysis of in situ coral-turf algal interactions

Viruses, microbes, and host macroorganisms form ecological units called holobionts. Here, a combination of metagenomic sequencing, metabolomic profiling, and epifluorescence microscopy was used to investigate how the different components of the holobiont including bacteria, viruses, and their associated metabolites mediate ecological interactions between corals and turf algae. The data demonstrate that there was a microbial assemblage unique to the coral-turf algae interface displaying higher microbial abundances and larger microbial cells. This was consistent with previous studies showing that turf algae exudates feed interface and coral-associated microbial communities, often at the detriment of the coral. Further supporting this hypothesis, when the metabolites were assigned a nominal oxidation state of carbon (NOSC), we found that the turf algal metabolites were significantly more reduced (i.e., have higher potential energy) compared to the corals and interfaces. The algae feeding hypothesis was further supported when the ecological outcomes of interactions (e.g., whether coral was winning or losing) were considered. For example, coral holobionts losing the competition with turf algae had higher Bacteroidetes-to-Firmicutes ratios and an elevated abundance of genes involved in bacterial growth and division. These changes were similar to trends observed in the obese human gut microbiome, where overfeeding of the microbiome creates a dysbiosis detrimental to the long-term health of the metazoan host. Together these results show that there are specific biogeochemical changes at coral-turf algal interfaces that predict the competitive outcomes between holobionts and are consistent with algal exudates feeding coral-associated microbes.

AB0511 INTERNATIONAL CONSENSUS ON ANCA TESTING AND INTERPRETATION BEYOND SYSTEMIC VASCULITIS

Background:

ANCA can be detected in sera from patients with autoimmune, inflammatory, infectious or neoplastic diseases.

Objectives:

To issue a Consensus Statement on ANCA testing and interpretation beyond systemic vasculitis.

Methods:

This Statement was prepared by a group of experts, based on the results of a comprehensive search in PubMed.

Results:

In certain settings beyond systemic vasculitis, ANCA may have diagnostic, clinical, and/or prognostic relevance. Testing for PR3- and MPO-ANCA by specific immunoassays should be performed in any patient with clinical features suggesting ANCA-associated vasculitis and in patients with anti-GBM disease and idiopathic interstitial pneumonia. Routine ANCA testing is not recommended in patients with connective tissue diseases (CTD), autoimmune liver diseases, inflammatory bowel diseases, infections, and/or malignancy unless there is evidence for small vessel vasculitis. ANCA testing by specific immunoassays may be useful in patients with rheumatoid arthritis, systemic sclerosis or primary Sjögren’s syndrome who have kidney disease with a nephritic sediment or in patients with systemic lupus erythematosus if a kidney biopsy shows prominent necrotizing and crescentic lesions or proliferative lupus nephritis. ANCA testing may be justified in patients with suspected autoimmune hepatitis type 1, who do not have conventional disease-related autoantibodies, or in patients with inflammatory bowel diseases in case of diagnostic uncertainty to discriminate ulcerative colitis from Crohn’s disease. In these cases, ANCA should be tested by indirect immunofluorescence since target antigens are not well characterized. ANCA against bactericidal/permeability-increasing protein may be a biomarker for deteriorating lung function and a poor prognosis in patients with cystic fibrosis.

Conclusion:

ANCA testing is clinically relevant not only in patients with manifestations suggesting systemic vasculitis, but also in patients with certain other disorders, particularly in patients with anti-GBM disease or idiopathic interstitial pneumonia.

Disclosure of Interests:

Sergey Moiseev Grant/research support from: This work was supported by the 5-100 Project, Sechenov University, Moscow, Jan Willem Cohen Tervaert: None declared, Yoshihiro Arimura: None declared, Dimitrios Bogdanos: None declared, Csernok Elena: None declared, Jan Damoiseaux: None declared, Marc Ferrante: None declared, Luis Felipe Flores-Suárez: None declared, Marvin Fritzler: None declared, Pietro Invernizzi: None declared, David Jayne Grant/research support from: ChemoCentryx, GSK, Roche/Genentech, Sanofi-Genzyme, Consultant of: Astra-Zeneca, ChemoCentryx, GSK, InflaRx, Takeda, Insmed, Chugai, Boehringer-Ingelheim, J. Charles Jennette: None declared, Mark Little: None declared, Stephen P. McAdoo: None declared, Pavel Novikov Grant/research support from: This work was supported by the 5-100 Project, Sechenov University, Moscow, Charles D. Pusey: None declared, Antonella Radice: None declared, Alan D. Salama: None declared, Judith Savige: None declared, Mårten Segelmark: None declared, Yehuda Shoenfeld: None declared, Renato Alberto Sinico: None declared, Maria Jose Rego de Sousa: None declared, Ulrich Specks: None declared, Benjamin Terrier: None declared, Athanasios Tzioufas: None declared, Severine Vermeire: None declared, Ming-hui Zhao: None declared, Xavier Bossuyt: None declared

A case of acute hypogonadism following taipan (Oxyuranus scutellatus) envenomation

A previously well man developed acute, marked tender bilateral gynaecomastia two months after confirmed taipan (Oxyuranus scutellatus) envenomation. He had had laboratory evidence of thrombotic microangiopathy (TMA) including microangiopathic haemolytic anaemia, thrombocytopenia and acute kidney injury. Scrotal ultrasound revealed bilateral testicular atrophy, his serum testosterone was repeatedly low, while his luteinising and follicle stimulating hormone were elevated. It is hypothesised that TMA-related testicular ischaemia was responsible for his primary gonadal failure and dramatic clinical presentation.

Electronic intravenous N-acetyl cysteine ordering tool: A retrospective review

OBJECTIVES

To examine if the electronic N-acetyl cysteine (NAC) order reduced prescribing errors.

METHODS

This was a retrospective chart review of all patients presenting over 2 years to Cairns Hospital ED with a discharge diagnosis of 'paracetamol overdose'. Data were collected for any patient who received i.v. NAC. Any error, and a description of the error such as dose, volume of fluid, time of infusion and incorrect patient weight was recorded.

RESULTS

There were 172 presentations with paracetamol poisoning with 86 receiving i.v. NAC. In the 75 (87%) where the electronic NAC order was used, there were no errors in dose of NAC, volume of i.v. fluid and length of time of infusion. In the 11 presentations where the manual NAC order was used, there were multiple errors identified.

CONCLUSION

The use of this electronic NAC order removed errors in NAC prescription and should be considered for prescribing and administering i.v. NAC.

The Virome of Cerebrospinal Fluid: Viruses Where We Once Thought There Were None

Traditionally, medicine has held that some human body sites are sterile and that the introduction of microbes to these sites results in infections. This paradigm shifted significantly with the discovery of the human microbiome and acceptance of these commensal microbes living across the body. However, the central nervous system (CNS) is still believed by many to be sterile in healthy people. Using culture-independent methods, we examined the virome of cerebrospinal fluid (CSF) from a cohort of mostly healthy human subjects. We identified a community of DNA viruses, most of which were identified as bacteriophages. Compared to other human specimen types, CSF viromes were not ecologically distinct. There was a high alpha diversity cluster that included feces, saliva, and urine, and a low alpha diversity cluster that included CSF, body fluids, plasma, and breast milk. The high diversity cluster included specimens known to have many bacteria, while other specimens traditionally assumed to be sterile formed the low diversity cluster. There was an abundance of viruses shared among CSF, breast milk, plasma, and body fluids, while each generally shared less with urine, feces, and saliva. These shared viruses ranged across different virus families, indicating that similarities between these viromes represent more than just a single shared virus family. By identifying a virome in the CSF of mostly healthy individuals, it is now less likely that any human body site is devoid of microbes, which further highlights the need to decipher the role that viral communities may play in human health.

The impact of the introduction of a toxicology service on the intensive care unit

Objective: To examine the impact of a clinical toxicology service on toxicology patients admitted to an intensive care department Methods: The authors performed a retrospective chart audit of all patients presenting to Cairns Emergency Department (ED) over a five-year period from 2011 to 2016 with a toxicology diagnosis requiring Intensive Care Unit (ICU) admission. They were divided into two groups: pre-toxicology (1 April 2011 to 30 September 2012), and post-toxicology service (1 October 2012 to 31 of March 2016) introduction. Patients were identified using ED and ICU databases. Patient charts were manually searched, and data entered on a preformatted data extraction tool. The data were statistically compared pre- versus post-toxicology service introduction using univariate (t-tests and Pearson's Chi Square) and multivariate modelling. Where appropriate, continuous variables were log transformed to enable parametric analyses. Results: There were 37 patients in the pre-toxicology and 102 in the post-toxicology group, with an increased median APACHE III J score in the post toxicology group (39 vs. 49). The introduction of a toxicology service was associated with statistically significant reductions in median ICU length of stay (LOS) (32.9 vs. 20.6 h), median duration of mechanical ventilation (29.1 vs. 20.6 h) and median time to psychiatry review (19.4 vs. 6.7 h). The reduction in ICU LOS remained statistically significant (p = 0.036) when adjusted by sex, age and duration of mechanical ventilation. There was neither increase in mortality, nor readmissions from EDSSU to ICU. Conclusions: This study has demonstrated that the introduction of a toxicology service was associated with a reduction in median ICU LOS, duration of mechanical ventilation and time to psychiatric review in patients with a toxicology diagnosis admitted to our ICU.

ORGAN DOSE ESTIMATION ACCOUNTING FOR UNCERTAINTY FOR PEDIATRIC AND YOUNG ADULT CT SCANS IN THE UNITED KINGDOM

Since our previous publication of organ dose for the pediatric CT cohort in the UK, there have been questions about the magnitude of uncertainty in our dose estimates. We therefore quantified shared and unshared uncertainties in empirical CT parameters extracted from 1073 CT films (1978-2008) from 36 hospitals in the study and propagated these uncertainties into organ doses using Monte Carlo random sampling and NCICT organ dose calculator. The average of 500 median brain and marrow doses for the full cohort was 35 (95% confidence interval: 30-40) mGy and 6 (5-7) mGy, respectively. We estimated that shared uncertainty contributed ~99% of coefficient of variation of median brain doses in brain scans compared to unshared uncertainty (1% contribution). We found that the previous brain doses were slightly underestimated for <1990 and overestimated for >1990 compared to the results in the current study due to the revised CTDI models based on CT films.