The deleterious effect of crossfostering in rat pups on hypoxic-ischemic injury tolerance and hypothermic neuroprotection

We study the effect of hypothermia (HT) following hypoxic-ischemic (HI) brain injury in postnatal day 7 (P7) rats. In 2015, new European Union animal transport regulations prompted a change in practice at the breeding facility, which henceforth crossfostered P3 litters to P8 older lactating dam prior to transportation. It is generally assumed that crossfostering does not significantly affect the experimental results. The aim of this study was to examine whether crossfostering affects our model consistency by modifying injury susceptibility and hypothermic neuroprotection. We analysed 219 pups (56 litters) from 11 experiments conducted between 2013 and 2015: 73 non-crossfostered and 146 crossfostered pups. At P7, all pups underwent unilateral common carotid artery ligation followed by 50min of hypoxia (8% O2, 36°C). Immediately after this mild insult, the pups were randomised to post-insult normothermia (NT) or HT treatment. Pups were culled at P14. Injury was assessed by area loss of the ipsilateral hemisphere and histopathology scoring of hippocampus, cortex, thalamus, and basal ganglia. Crossfostered pups had double the injury compared to non-crossfostered pups irrespective of treatment group. Hypothermic neuroprotection was statistically significant, but with a smaller and less consistent effect in crossfostered pups (relative neuroprotection 16% vs. 31% in non-crossfostered). These results demonstrate hypothermic neuroprotection following a mild HI insult. A representative subset of 41 animals were also assessed for evidence of microglial reactivity, however no detectable difference in microglial reactivity was observed between any of the groups. In conclusion, crossfostering alters outcomes in our established model through reduced insult tolerance and variable neuroprotection. Crossfostering as a common breeding practice is a largely unexplored variable in animal research that may result in invalid research conclusions if inadequately adjusted for by larger group sizes. As a result, crossfostering is likely to be inconsistent with the principles of replacement, reduction, and refinement.

Understanding Source-Related Influences on Physicians’ Translating Comparative Effectiveness Research into Patient Care: Results from a Study of Cardiologists

Comparative effectiveness research (CER), which refers to an evaluation of the clinical effectiveness of two or more medical interventions that are used to treat the same condition, has the potential to inform decision-making in both policy circles and physicians’ exam rooms. The ability of stakeholders to translate that research into practice has important implications for health outcomes, but the impact of information sources on physicians in translating CER remains understudied. This project examines the source-related influences on and motivations of cardiologists with respect to willingness to make changes in their practice based on emerging CER results. The results from this survey of cardiologists (N = 42) indicate that the source of information (including perceived credibility of those sources) matters greatly to cardiologists when deciding whether to make a change in practice. These findings suggest data-based implications for researchers and practitioners that are engaged in closing the CER translation gap.

Treatment of Cardiac Surgical Wounds with Silver Dressings

Introduction. Mediastinitis is a deadly surgical site infection (SSI) after cardiac surgery. Although rare, mortality is as high as 47%. Best practices for infection prevention to eliminate this deadly complication must be identified. Surgical dressings impregnated with silver have been shown to reduce SSIs in other surgical specialties. This aim of this study is to determine if the routine use of silver surgical dressings is beneficial to prevent mediastinitis after cardiac surgery. Methods. A single-center retrospective study was performed on patients who underwent sternotomy from 2016 to 2018 at the University of Kansas Medical Center. Prior to June 2017, all cardiac surgical patients were treated with gauze surgical dressings and is designated Group A. The routine use of silver-impregnated surgical dressings was implemented in June 2017, patients after this change in practice are designated Group B. Patient characteristics and rates of deep and superficial sternal wound infections (SWI) were compared. Results. There were 464 patients in Group A and 505 in Group B. There were seven SWIs in Group A (7/464, 1.5%) and five in Group B (5/505, 1%; p = 0.57). Of these, there was one deep SWI per group (p = 0.61) and six superficial SWIs in Group A compared to four in Group B (p = 0.74). Severe COPD was higher in Group A (p = 0.04) and peak glucose was higher in Group B (p = 0.02). Conclusions.The analysis conferred no benefit with silver-impregnated surgical dressings to prevent mediastinitis. Choice of gauze surgical dressings may be preferable to reduce cost.

Fetal surveillance from 39 weeks’ gestation: an alternative to earlier induction of labour to reduce stillbirth in South Asian born women? A Retrospective Cohort Study

Objectives: In July 2017, Victoria’s largest maternity service implemented a new clinical guideline aimed to reduce the rates of stillbirth at term for South Asian-born women. Here we present the evaluation of the change in care on rates of stillbirth, neonatal and obstetric interventions. Design: Cohort Study Setting: Victoria’s largest metropolitan university-affiliated teaching hospital. Population: All women receiving antenatal care who gave birth in the term period between January 2016 and December 2020. Methods: Differences in rates of stillbirths, neonatal deaths, perinatal morbidities, and interventions after July 2017 were determined. Multigroup interrupted time-series analysis was used to assess changes in rates of induction of labour. Main Outcome Measures: Rates of stillbirths, neonatal deaths, perinatal morbidities, and obstetric interventions. Results: 3506 south Asian-born women gave birth prior to, and 8532 after the change. There was a 64% reduction in term stillbirth (95%CI 87% to 2%; p=0.047) for south Asian-born women after the change in practice from 2.3 per 1000 births to 0.8 per 1000 births. The rates of early neonatal death (3.1 per 1000 vs 1.3 per 1000; p=0.03) and SCN admission (16.5% vs 11.1%; p<0.001) also decreased. There were no significant differences in admission to NICU, Apgar<7 at 5 minutes, birthweight or differences in the trends of induction of labour per month. Conclusions: Fetal monitoring from 39 weeks’ may offer an alternative to routine earlier induction of labour to reduce the rates of stillbirth without causing an increase in neonatal morbidity or obstetric interventions.

EP.FRI.849 Quality Improvement Project for Management of Unstable Ankle Fracture in Scunthorpe General Hospital

Introduction In SGH, little emphasis is placed on ankle fracture as compared to hip fracture. Hence, an audit was done to compare management of unstable ankle fracture in adherence to BOAST guidelines. It was found out that few aspects of management in A&E were inadequate. Analyzing the root cause of non-adherence to guideline can lead to better care for these patients. Aim Primary aim is to ensure that ankle fractures are treated effectively in line with BOAST guidelines. Secondary aim is to ensure that ankle fractures are treated in a timely manner. Change in practice Discussion was held between Orthopaedic consultant and A&E consultant. Firstly, poster displaying algorithm for ankle fracture management displayed in A&E. Secondly, Orthopaedics doctor would come to A&E to reduce fracture after first failed attempt. Methods Prospective data is collected. Patients with unstable ankle fracture who are admitted in SGH are assessed in regards to BOAST guidelines via WebV, PACS and clinical notes. Results Major improvement is seen in different aspects. The documentation of neurovascular assessment and skin integrity in A&E department is improved by 57%. Additional radiographs of the whole leg when clinical examination suggests a more proximal fracture of the fibula (Maisonneuve injury) was performed in 60% more patients as compared to previously. Adequacy of reduction done in A&E is improved by 25%. Conclusion Small changes can make a big difference. Good communication and teamwork between different departments is the best way to provide better care for patients.

TP6.1.2 Laparoscopic subtotal cholecystectomy; change in practice over a 10-year period

Aim Laparoscopic subtotal cholecystectomy is a safe strategy to avoid bile duct injury when a critical view of safety cannot be obtained. This technique may result in fewer open conversions and was introduced in our DGH in 2013. This study describes the change in practice at our centre following introduction of subtotal cholecystectomy. Method Retrospective case series included consecutive cholecystectomies over a ten-year period in a single institution. Cases were divided into subgroups based on operation date; 2009-2012 (Group A) and 2013-2019 (Group B). These groups represent pre- (Group A) and post- (Group B) introduction of laparoscopic subtotal cholecystectomy. Primary outcome was the proportion of patients undergoing laparoscopic total cholecystectomy, laparoscopic sub-total and lap-converted to open cholecystectomy. Secondary outcomes included incidence of bile leak, complication rate, return to theatre, and length of stay. Results There were 4248 cases; 1387 in Group A, and 2861 in Group B. The rate of open conversions was higher in Group A than Group B (4.7% vs. 2.8%, p = 0.003). The rate of laparoscopic total cholecystectomy was higher in Group A than Group B (95.3% vs. 92.8%, p = 0.013). In the subtotal group (n = 114, 3.9% of Group B); 14 (12.3%) patients had bile leak requiring ERCP, 6 (5.3%) underwent re-laparoscopy for inadequate biliary drainage, and median LOS was 2 days. Conclusion Laparoscopic subtotal cholecystectomy has proven to be a safe technique at our centre, reducing the rate of open conversion and length of stay, with a low rate of reintervention for bile leak.

TP10.1.9End Colostomy Formation: Change in Practice during the Covid-19 Pandemic

Aim Intercollegiate guidance favoured the increased stoma formation during the early phases of the Covid-19 pandemic due to uncertainty around the availability of critical care beds and peri-operative impact of SARS-CoV-2. This study assessed the impact the Covid-19 pandemic and changing guidance had on end colostomy formation. Methods Data were reviewed from a prospectively collected database on the number of end colostomies formed over a 10-month period from 1st March to 31st December 2020. Comparison was made with the same period in 2019. Details were confirmed using clinical letters. Results There was an overall 11.5% increase in the number of end colostomies formed in the in the same 10-month period in 2020 compared with 2019 (87 vs 78). The increase in end colostomy formation was most marked in the 3-month period of March to May, with 36.8% more end colostomies formed in 2020 than in 2019 (26 vs 19). The number of end colostomies formed in the remaining 7-month period of June to December was similar in the two years (61 vs 59). Conclusions There was a change in surgical practice in favour of stoma formation, which peaked in the period of March to May 2020. This coincided with a time of maximum uncertainty surrounding the Covid-19 pandemic and changing intercollegiate guidance. The change in practice has implications for patients longer term and may impact on the service in the post-Covid recovery period with patients requesting reversal procedures.

TP6.2.15 Staging Laparoscopy and Peritoneal Cytology for Gastric and Gastro-oesophageal Junction Malignancy: an Audit from a Single Oesophagogastric Resection Centre

Aims AUGIS recommends staging laparoscopy in all gastric cancers and selected gastro-oesophageal junction (GOJ) cancers. We previously audited our practice of staging laparoscopy and peritoneal cytology and found that in a cohort of 158 consecutive patients, no tumours less than T3 with negative nodes had positive cytology, resulting in change in practice to selectively use peritoneal cytology in patients with a T-stage of 3 and above or N+ disease. Our aim was to assess the impact of this audit on current practice. Methods We retrospectively reviewed the notes of patients undergoing staging laparoscopy and oesophagogastroduodenoscopy (OGD) identified by MDT from January 2019 to December 2019. Patients who underwent resection on the same day were excluded. Results 63 patients underwent staging laparoscopy and OGD, 54 for GOJ and 9 for gastric disease. The majority were staged as T3 or T4a (81%). As a result of staging laparoscopy and OGD, 4 (6%) patients were changed from curative to palliative pathway, 2 (3%) of whom had positive cytology. No patients had positive peritoneal cytology for a T stage of 2 and below with no positive nodes, further demonstrating the safety of the recommendation. Conclusions Peritoneal cytology has a low yield in changing the clinical course of patients but can upstage up to 6% of patients. The re-audit backs up the previous guidance in the safety of using our current threshold for recommending peritoneal cytology and potentially prevents delaying treatment while waiting for cytology results.

EP.FRI.511 Optimising Ambulatory Ultrasound in Emergency Surgery

Aims Service provision and assessing the impact of future innovations can best be assessed by accurate reproducible data collection. The traditional model for our ambulatory surgical clinic with ultrasound allowed booking directly from the Emergency Department (ED) without discussion with the Surgical Team. We questioned whether this was the correct model and changed to a model of discussion with the Surgical team before booking in an effort to better utilise resource and reduce unnecessary footfall in the hospital. Methods We reviewed the outcome data of consecutive ambulatory ultrasound clinic referrals before and after implementation of this change in practice (1 month before and after the change) Results Ninety four ambulatory Ultrasound referrals were reviewed. In the first cohort 30 of 50 patients came directly from ED without discussion. A positive USS report was recorded in 8 of the 30 (27% USS positivity rate). After the change in practice to discuss with the surgical team, 11 of 43 patients originated primarily from ED with a positive finding in 4 patients (36%). Conclusions A key aim of service improvement is to optimise / improve utilisation of resource. This must be achieved without missing pathology. In this study we reduced the number of scans performed by ED whilst increasing the likelihood of a positive scan. This change in practice better utilised resource and reduced unnecessary footfall in the hospital.