Subcutaneous immunoglobulin replacement therapy in patients with immunodeficiencies - impact of drug packaging and administration method on patient reported outcomes.

BACKGROUND: Here, the perspective of patients with primary and secondary immunodeficiency receiving subcutaneous immunoglobulin (SCIg) via introductory smaller size pre-filled syringes (PFS) or vials were compared. METHODS: An online survey was conducted in Canada by the Association des Patients Immunodéficients du Québec (APIQ) (10/2020-03/2021). Survey questions included: reasons for choosing SCIg packaging and administration methods, training experiences, infusion characteristics, and switching methods. The survey captured structured patient-reported outcomes: treatment satisfaction and its sub-domains, symptom state, general health perception, and physical and mental function. Respondents using PFS were compared with vial users, overall and stratified by their administration method (pump or manual push). RESULTS: Of the 132 total respondents, 66 respondents used vials, with 38 using a pump and 28 using manual push. PFS (5 and 10 mL sizes) were being used by 120 respondents, with 38 using a pump and 82 using manual push. PFS users were associated with a 17% lower median (interquartile range) SCIg dose (10 [8, 12] vs. 12 [9, 16] g/week, respectively), a significantly shorter infusion preparation time (15 [10, 20] vs. 15 [10, 30] mins, respectively), and a trend for shorter length of infusion (60 [35, 90] vs. 70 [48, 90] mins, respectively) compared with those on vials. Patient-reported treatment satisfaction scores were overall similar between vial and PFS users (including on the domains of effectiveness and convenience), except for a higher score for vials over PFS on the domain of global satisfaction (p=0.02). CONCLUSIONS: Consistent with prescribing that reflects a recognition of less wastage, PFS users were associated with a significantly lower SCIg dose compared with vial users. PFS users were also associated with shorter pre-infusion times, reflecting simpler administration mechanics compared with vial users. Higher global satisfaction with treatment among vial users compared with PFS users was consistent with users being limited to smaller PFS size options in Canada during the study period. Patient experience on PFS is expected to improve with the introduction of larger PFS sizes. Overall, treatment satisfaction for SCIg remains consistently high with the introduction of PFS packaging compared with vials.

Clinical characteristics of people with intellectual disability admitted to hospital with constipation: identifying possible specific high-risk factors.

BACKGROUND: People with intellectual disabilities (ID) die on an average 20 years earlier to the general population. They have higher rates of multimorbidity and polypharmacy. Around 25% of people with ID report chronic constipation. The England Learning Disabilities Mortality Review found that nearly 25% of deaths identified constipation as a long-term health problem. However, the likely risk factors for constipation related harm are poorly enumerated. We sought to identify possible specific high-risk factors by examining the clinical characteristics of people with ID admitted to hospital with constipation. METHODS: Data of people with ID admitted with constipation in two general hospitals covering a population of 1.3 million from 2017 to 2022 were reported using the STROBE guideline for cohort studies. Collected data included age, gender, intellectual disability severity, recorded medication, presenting complaint and co-morbidities. The medication anticholinergic burden was calculated using the anticholinergic burden scale. Continuous variables were summarised by mean and standard deviation if normally distributed, with categorical variables summarised by the number and percentage in each category. RESULTS: Of 46 admissions (males 52%), 57% had moderate to profound ID, 37% had epilepsy, 41% prescribed antiseizure medication (ASM) and 45% were on laxatives. Average age was 46 years. The anticholinergic burden score mean was 2.3 and median, one. CONCLUSIONS: We can hypothesise that people with more severe ID, suffering from epilepsy and on ASM may be more at risk of developing severe constipation. Some admissions may be avoided with earlier use of laxatives in the community.

Awareness of social care needs in people with epilepsy and intellectual disability.

BACKGROUND: Nearly a quarter of people with intellectual disability (ID) have epilepsy with large numbers experiencing drug-resistant epilepsy, and premature mortality. To mitigate epilepsy risks the environment and social care needs, particularly in professional care settings, need to be met. PURPOSE: To compare professional care groups as regards their subjective confidence and perceived responsibility when managing the need of people with ID and epilepsy. METHOD: A multi-agency expert panel developed a questionnaire with embedded case vignettes with quantitative and qualitative elements to understand training and confidence in the health and social determinants of people with ID and epilepsy. The cross-sectional survey was disseminated amongst health and social care professionals working with people with ID in the UK using an exponential non-discriminative snow-balling methodology. Group comparisons were undertaken using suitable statistical tests including Fisher's exact, Kruskal-Wallis, and Mann-Whitney. Bonferroni correction was applied to significant (p < 0.05) results. Content analysis was conducted and relevant categories and themes were identified. RESULTS: Social and health professionals (n = 54) rated their confidence to manage the needs of people with ID and epilepsy equally. Health professionals showed better awareness (p < 0.001) of the findings/recommendations of the latest evidence on premature deaths and identifying and managing epilepsy-related risks, including the relevance of nocturnal monitoring. The content analysis highlighted the need for clearer roles, improved care pathways, better epilepsy-specific knowledge, increased resources, and better multi-disciplinary work. CONCLUSIONS: A gap exists between health and social care professionals in awareness of epilepsy needs for people with ID, requiring essential training and national pathways.

Autologous stem cell transplantation for multiple myeloma patients with chronic kidney disease: a safe and effective option.

Chronic Kidney Disease (CKD) is a frequent complication in patients with multiple myeloma (MM) and is associated with adverse outcomes. The use of autologous stem cell transplantation (ASCT) has improved disease outcomes, however, the safety and efficacy of ASCT in patients with CKD has been the subject of debate. To investigate this, we conducted a retrospective analysis of 370 MM patients who underwent their first ASCT, including those with mild, moderate and severe CKD as well as normal renal function at the time of transplant. No significant difference in ASCT-related mortality, Progression-Free or Overall Survival was noted between the different renal function groups. A decline in estimated glomerular filtration rate (eGFR) at 1-year of >8.79% was associated with poorer overall survival (p < 0.001). The results of this study show that ASCT is a safe and effective option for myeloma patients with CKD, including those on dialysis. Patients who demonstrate renal deterioration at 1-year post-transplant should be closely monitored as this is a predictor for poor survival.

Home viewing of educational video improves patient understanding of Mohs micrographic surgery.

BACKGROUND: Educational videos improve patient knowledge of wound care and skin cancer. However, the effect of viewing an educational video at home before undergoing Mohs micrographic surgery (MMS) has not been demonstrated. AIM: To evaluate the use of an educational video to improve patient understanding of MMS. METHODS: Patients scheduled to undergo MMS were randomized to receive standard patient education, or standard patient education with an additional video developed by the authors. The educational material was posted to patients along with the details of their MMS appointment. Both groups answered questionnaires to assess their knowledge of MMS, and to measure their anxiety and satisfaction. RESULTS: Patients who watched the educational video scored higher on the knowledge questionnaire than did patients in the control group (0.8, 95% CI 0.3 to 1.4, P < 0.01), but were not statistically less anxious (-0.7, 95% CI -2.6 to 1.3, P = 0.50). Overall, patients undergoing MMS were satisfied. CONCLUSION: Home viewing of an educational video before MMS can improve patient understanding.

The ability of post-chemoradiotherapy DWI ADCmean and 18F-FDG SUVmax to predict treatment outcomes in head and neck cancer: impact of human papilloma virus oropharyngeal cancer status.

OBJECTIVES: To evaluate the ability of post-chemo-radiotherapy (CRT) diffusion-weighted-MRI apparent diffusion coefficient (ADCmean) and 18F-FDG PET maximum standardized uptake value (SUVmax) to predict disease-free survival (DFS) in head and neck squamous cell carcinoma (HNSCC), and to determine whether this ability is influenced by human papillomavirus oropharyngeal cancer (HPV-OPC) status. METHODS: This prospective cohort observational study included 65 participants (53 male, mean ± SD age 59.9 ± 7.9 years, 46 HPV-OPC) with stage III or IV HNSCC. Primary tumour and nodal ADCmean (pre-treatment, 6- and 12-weeks post-CRT) and SUVmax (12-weeks post-CRT) were measured. Variables were compared with 2-year DFS (independent t-test/Mann-Whitney test) and overall DFS (Cox regression), before and after accounting for HPV-OPC status. Variables were also compared between HPV-OPC and other HNSCC subgroups after stratifying for DFS. RESULTS: Absolute post-CRT ADCmean values predicted 2-year DFS and overall DFS for all participants (p = 0.03/0.03, 6-week node; p = 0.02/0.03 12-week primary tumour) but not in the HPV-OPC subgroup. In participants with DFS, percentage interval changes in primary tumour ADCmean at 6- and 12-weeks were higher in HPV-OPC than other HNSCC (p = 0.01, 6 weeks; p = 0.005, 12 weeks). The 12-week post-CRT SUVmax did not predict DFS. CONCLUSION: Absolute post-CRT ADCmean values predicted DFS in HNSCC but not in the HPV-OPC subgroup. Amongst participants with DFS, post-CRT percentage interval changes in primary tumour ADCmean were significantly higher in HPV-OPC than in other HNSCC. Knowledge of HPV-OPC status is crucial to the clinical utilisation of post-CRT DWI-MRI for the prediction of outcomes.

Impact of severe acute respiratory syndrome coronavirus 2 on ectopic pregnancy management in the United Kingdom: a multicentre observational study.

OBJECTIVE: To describe the impact of coronavirus disease 2019 (COVID-19) on the management of women with ectopic pregnancy. DESIGN: A multicentre observational study comparing outcomes from a prospective cohort during the pandemic [COVID-19-ectopic pregnancy registry (CEPR)] compared with a historical pre-pandemic cohort [non-COVID-19-ectopic pregnancy registry (NCEPR)]. SETTING: Five London university hospitals. POPULATION AND METHODS: Consecutive patients diagnosed clinically and/or radiologically with ectopic pregnancy (March 2020-August 2020) were entered into the CEPR and results were compared with the NCEPR cohort (January 2019-June 2019). An adjusted analysis was performed for potentially confounding variables. MAIN OUTCOME MEASURES: Patient demographics, management (expectant, medical and surgical), length of treatment, number of hospital visits (non-surgical management), length of stay (surgical management) and 30-day complications. RESULTS: Three hundred and forty-one women met the inclusion criteria: 162 CEPR and 179 NCEPR. A significantly lower percentage of women underwent surgical management versus non-surgical management in the CEPR versus NCEPR (58.6%; 95/162 versus 72.6%; 130/179; P = 0.007). Among patients managed with expectant management, the CEPR had a significantly lower mean number of hospital visits compared with NCEPR (3.0, interquartile range [IQR] [3, 5] versus 9.0, [5, 14]; P = <0.001). Among patients managed with medical management, the CEPR had a significantly lower median number of hospital visits versus NCEPR (6.0, [5, 8] versus 9, [6, 10]; P = 0.003). There was no observed difference in complication rates between cohorts. CONCLUSION: Women were found to undergo significantly higher rates of non-surgical management during the COVID-19 first wave compared with a pre-pandemic cohort. Women managed non-surgically in the CPER cohort were also managed with fewer hospital attendances. This did not lead to an increase in observed complication rates. TWEETABLE ABSTRACT: A higher rate of non-surgical management of ectopic pregnancy during the COVID-19 pandemic did not increase complication rates.

A randomised clinical trial of methotrexate points to possible efficacy and adaptive immune dysfunction in psychosis.

NMDA autoantibody encephalitis presenting as schizophrenia suggests the possible role of adaptive cell-mediated immunity in idiopathic schizophrenia. However, to our knowledge there have been no trials of the immune-suppressant methotrexate in schizophrenia. We tested if low-dose methotrexate as used in the treatment of systemic autoimmune disorders would be tolerable and effective in people with schizophrenia in a feasibility study. Ninety-two participants within 5 years of schizophrenia diagnosis were recruited from inpatient and outpatient facilities in Karachi, Pakistan. They were randomised to receive once weekly 10-mg oral methotrexate (n = 45) or matching placebo (n = 47) both with daily 5-mg folic acid, in addition to treatment as usual for 12 weeks. There were eight dropouts per group. Side effects were non-significantly more common in those on methotrexate and were not severe. One person developed leukopenia. Positive symptom scores improved more in those receiving methotrexate than placebo (ß = -2.5; [95% CI -4.7 to -0.4]), whereas negative symptoms were unaffected by treatment (ß = -0.39; [95% CI -2.01 to 1.23]). There were no immune biomarkers but methotrexate did not affect group mean leucocyte counts or C-reactive protein. We conclude that further studies are feasible but should be focussed on subgroups identified by advances in neuroimmune profiling. Methotrexate is thought to work in autoimmune disorders by resetting systemic regulatory T-cell control of immune signalling; we show that a similar action in the CNS would account for otherwise puzzling features of the immuno-pathogenesis of schizophrenia.

Risk factors for severe disease in patients admitted with COVID-19 to a hospital in London, England: a retrospective cohort study.

COVID-19 has caused a major global pandemic and necessitated unprecedented public health restrictions in almost every country. Understanding risk factors for severe disease in hospitalised patients is critical as the pandemic progresses. This observational cohort study aimed to characterise the independent associations between the clinical outcomes of hospitalised patients and their demographics, comorbidities, blood tests and bedside observations. All patients admitted to Northwick Park Hospital, London, UK between 12 March and 15 April 2020 with COVID-19 were retrospectively identified. The primary outcome was death. Associations were explored using Cox proportional hazards modelling. The study included 981 patients. The mortality rate was 36.0%. Age (adjusted hazard ratio (aHR) 1.53), respiratory disease (aHR 1.37), immunosuppression (aHR 2.23), respiratory rate (aHR 1.28), hypoxia (aHR 1.36), Glasgow Coma Scale <15 (aHR 1.92), urea (aHR 2.67), alkaline phosphatase (aHR 2.53), C-reactive protein (aHR 1.15), lactate (aHR 2.67), platelet count (aHR 0.77) and infiltrates on chest radiograph (aHR 1.89) were all associated with mortality. These important data will aid clinical risk stratification and provide direction for further research.

Subcutaneous immunoglobulin in primary immunodeficiency - impact of training and infusion characteristics on patient-reported outcomes.

BACKGROUND: Subcutaneous immunoglobulin (SCIG) is increasingly utilized in primary immunodeficiency (PI). Understanding factors associated with treatment experience and satisfaction can optimize patient outcomes. We analyzed Immune Deficiency Foundation (IDF) survey data to evaluate patient-reported outcomes (PROs) in relation to SCIG training and infusion characteristics. Respondents' PRO scores were rank ordered into 'best', 'intermediate', and 'worst' tertiles. Predicted probabilities of being in the best tertile with any combination of characteristics were generated for each PRO. RESULTS: In 366 SCIG respondents, higher odds of being in the best PRO tertile were driven by favorable training characteristics (particularly, higher confidence post-training and no training barriers) and efficient infusions (infusion preparation ≤20 min and actual infusion < 2 h). Age (≤17 years old) and treatment experience (> 2 years) increased the odds of being in the best tertiles. Compared with the least favorable training/infusion characteristics, those with the most favorable training/infusion characteristics had higher predicted probabilities of being in the best tertiles: TSQM side effects, 59% vs 4%; convenience, 52% vs 4%; effectiveness, 27% vs 13%; global, 26% vs 3%; PROMIS Fatigue, 44% vs 18%. CONCLUSIONS: Increased experience with SCIG consistently improved PROs, but our findings predicted that enhanced training and infusion characteristics improve patient treatment satisfaction beyond that achieved by experience alone.

The impact of copper impregnated wound dressings on surgical site infection following caesarean section: a double blind randomised controlled study.

OBJECTIVE: To investigate the effect of copper impregnated wound dressings on the surgical site infection (SSI) rate following caesarean section (CS). DESIGN: Single centre double blind randomised controlled trial. PARTICIPANTS: Women aged 18 years or over who had a CS. INTERVENTIONS: All women were randomised to receive either a copper-oxide impregnated wound dressing (study group) or a non-copper wound dressing (control group). MAIN OUTCOME MEASURES: The primary study outcome was the incidence of SSI within a 30-day period from CS, assessed via a telephone questionnaire. Secondary outcomes were length of hospital stay, and readmission rate. RESULTS: 324 women were enrolled in the study of whom 159 were randomised to the study group and 165 to the control group. The follow up rate was 97.5%. A total of 78 women (24.1%) developed an SSI within 30 days following CS; 29 (18.2%) in the study group and 49 (29.7%) controls (P = 0.037, relative risk reduction (RRR) of 38.7%). The incidence of superficial/deep SSI was not significantly different (24.2% vs. 17.6%, P = 0.257), however a significant relative risk reduction of 80.3% for Organ/Space SSI was observed in the study group (12.7% vs. 2.5%, P = 0.002). Length of hospital stay, and readmission rate did not vary significantly between groups. CONCLUSIONS: This is the first study to demonstrate a significant reduction in SSI rates following CS with the use of copper impregnated wound dressings. The high SSI rate confirms the importance of new strategies to reduce the infection rate. Copper is a natural remedy which could potentially reduce hospital acquired infections without the use of antibiotics and its associated risks of antibiotic resistance.

Comparison between high-resolution water-perfused anorectal manometry and THD® Anopress anal manometry: a prospective observational study.

AIM: Anorectal physiology tests provide a functional assessment of the anal canal. The aim of this study was to compare the results generated by standard high-resolution water-perfused manometry (WPM) with the newer THD® Anopress manometry system. METHOD: This was a prospective observational study. Conventional manometry was carried out using a water-perfused catheter with high-resolution manometry and compared with the Anopress system with air-filled catheters. All patients underwent the two procedures successively in a randomized order. Time to arrive at the resting pressure plateau, resting, squeeze, straining pressure and visual analogue scale (VAS) scores for pain were recorded. A qualitative analysis of the two devices was performed. RESULTS: Between 2016 and 2017, 60 patients were recruited. The time from insertion of the catheter to arriving at the resting pressure plateau was significantly lower with the Anopress compared with WPM: 12 s [interquartile range (IQR) 10-17 s] versus 100 s (IQR 67-121 s) (P < 0.001). A strong correlation between the manometric values of WPM and the Anopress was observed. Both procedures were well tolerated, although the VAS score for insertion of the WPM catheter was significantly higher. The Anopress was easier to use and more time-efficient than the WPM. CONCLUSION: The pressure values obtained with Anopress correlated well with those of conventional manometry. The Anopress has the advantage of being less time-consuming, user-friendly and better tolerated by patients.

The effect of a novel Bayesian penalised likelihood PET reconstruction algorithm on the assessment of malignancy risk in solitary pulmonary nodules according to the British Thoracic Society guidelines.

PURPOSE: British Thoracic Society (BTS) guidelines advocate using FDG PET-CT with the Herder model to estimate malignancy risk in solitary pulmonary nodules (SPNs). Qualitative and semi-quantitative assessment of SPN uptake is based upon analysis of Ordered Subset Expected Maximisation (OSEM) PET images. Our aim was to assess the effect of a Bayesian Penalised Likelihood (BPL) PET reconstruction on the assessment of SPN FDG uptake and estimation of malignancy risk (Herder score). METHODS: Subjects with SPNs who underwent FDG PET-CT between 2014-2017, with histological confirmation of malignancy or histological/imaging follow-up confirmation of benignity were included. Two blinded readers independently classified SPN uptake on both OSEM and BPL (BTS score; 1 = none; 2 = ≤ mediastinal blood pool (MBP); 3 = >MBP but ≤ 2x liver; 4 = >2x liver), with resultant calculation of the Herder score (%) for both reconstructions. RESULTS: 97 subjects with 75 (77%) malignant SPNs were included. BPL increased the BTS score in 25 (26%) SPNs; 9 SPNs (7 malignant) increased from BTS score 2 to 3, 16 (13 malignant) from BTS score 3 to 4, with a mean Herder score increase of 18 ±â€¯22%. The mean Herder score for all SPNs with BPL was higher than OSEM (73 ±â€¯29 vs 68 ±â€¯32%, p = 0.001). There was no difference in Herder model diagnostic performance between BPL and OSEM, with similar areas under the curve (0.84 vs 0.83, p = 0.39). CONCLUSION: BPL increases the Herder score in 26% of SPNs compared to OSEM but does not alter the diagnostic performance of the Herder model.

Endoscopic Resections in Inflammatory Bowel Disease: A Multicentre European Outcomes Study.

BACKGROUND AND AIMS: Inflammatory bowel disease is associated with an increased risk of colorectal cancer, with estimates ranging 2-18%, depending on the duration of colitis. The management of neoplasia in colitis remains controversial. Current guidelines recommend endoscopic resection if the lesion is clearly visible with distinct margins. Colectomy is recommended if complete endoscopic resection is not guaranteed. We aimed to assess the outcomes of all neoplastic endoscopic resections in inflammatory bowel disease. METHODS: This was a multicentre retrospective cohort study of 119 lesions of visible dysplasia in 93 patients, resected endoscopically in inflammatory bowel disease. RESULTS: A total of 6/65 [9.2%] lesions <20 mm in size were treated by ESD [endoscopic submucosal dissection] compared with 59/65 [90.8%] lesions <20 mm treated by EMR [endoscopic mucosal resection]; 16/51 [31.4%] lesions >20 mm in size were treated by EMR vs 35/51 [68.6%] by ESD. Almost all patients [97%] without fibrosis were treated by EMR, and patients with fibrosis were treated by ESD [87%], p < 0.001. In all, 49/78 [63%] lesions treated by EMR were resected en-bloc and 27/41 [65.9%] of the ESD/KAR [knife-assisted resection] cases were resected en-bloc, compared with 15/41 [36.6%] resected piecemeal. Seven recurrences occurred in the cohort. Seven complications occurred in the cohort; six were managed endoscopically and one patient with a delayed perforation underwent surgery. CONCLUSIONS: Larger lesions with fibrosis are best treated by ESD, whereas smaller lesions without fibrosis are best managed by EMR. Both EMR and ESD are feasible in the management of endoscopic resections in colitis.

Differential rates of group B streptococcus (GBS) colonisation in pregnant women in a racially diverse area of London, UK: a cross-sectional study.

OBJECTIVE: To describe the epidemiology of maternal group B streptococcus (GBS) colonisation by racial group. DESIGN: Cross-sectional study. SETTING: Antenatal clinics in London North West University Healthcare NHS Trust. POPULATION: Pregnant women. METHODS: Group B streptococcus (GBS) colonisation status was recorded during a screening programme for the prevention of invasive early-onset GBS infection. Information regarding age, address, ethnicity, parity, mode of delivery, body mass index (BMI), and diabetes was routinely collected. Data were analysed by multivariable analysis. MAIN OUTCOME MEASURES: Association between GBS colonisation and putative risk factors. RESULTS: Overall, 29.1% (1836/6309) of the women were colonized with GBS. Multivariable analysis showed significantly higher colonisation among women of black African origin (39.5%; OR = 1.57) compared with white British women (27.4%), and lowest colonisation in women of South Asian origin (23.3%; OR = 0.8). Higher parity (≥2) was associated with higher colonisation (35.3%), with the odds of colonisation over 40% higher than for nulliparous women. Increasing BMI was associated with an incremental rise in colonisation from 23 to 35%. Colonisation was not associated with age, season or mode of testing. CONCLUSION: This study identified high maternal GBS colonisation rates in a racially and socially diverse population. The highest rates were seen in women of black African origin and also with higher parity and BMI. Further research is needed to understand the relationship between these factors and rectovaginal colonisation. TWEETABLE ABSTRACT: Study of group B streptococcus colonisation in pregnant women in London shows highest rates in black African women and those with high BMI and parity.

Outbreak report of investigation and control of an outbreak of Panton-Valentine Leukocidin-positive methicillin-sensitive Staphylococcus aureus (PVL-MSSA) infection in neonates and mothers.

BACKGROUND: In January 2011, there was an outbreak of Panton-Valentine Leukocidin-positive methicillin-sensitive Staphylococcus aureus (PVL-MSSA) infection in a neonatal unit (NNU). We describe the investigation and control of an outbreak of PVL-MSSA infection in neonates. SETTING: Neonatal unit in West London. METHODS: We performed descriptive and analytical (case-control study) epidemiological investigations. Microbiological investigations including screening of MSSA isolates by PCR for the presence of the luk-PV, mecA and mecC genes and comparison of isolate with Pulsed field gel electrophoresis (PFGE). Control measures were also introduced. RESULTS: Sixteen babies were infected/colonised with the outbreak strain. Of these, one baby developed blood stream infection, 12 developed skin pustules and four babies were colonised. Four mothers developed breast abscesses. Eighty-seven babies in the unit were screened and 16 were found to have same PVL-MSSA strain (spa type t005, belonging to MLST clonal complex 22). Multivariate analysis showed gestational age was significantly lower in cases compared to controls (mean gestational age: 31.7 weeks v 35.6 weeks; P = 0.006). Length of stay was significantly greater for cases, with a median of 25 days, compared to only 6 days for controls (P = 0.01). Most (88%) cases were born through caesarean section, compared to less than half of controls. (P = 0.002). No healthcare worker carriers and environmental source was identified. The outbreak was controlled by stopping new admissions to unit and reinforcing infection control precautions. The outbreak lasted for seven weeks. No further cases were reported in the following year. CONCLUSIONS: Infection control teams have to be vigilant for rising prevalence of particular S. aureus clones in their local community as they may cause outbreaks in vulnerable populations in healthcare settings such as NNUs.

A meta-analysis comparing open anterior component separation with posterior component separation and transversus abdominis release in the repair of midline ventral hernias.

PURPOSE: This study aims to compare the outcomes of posterior component separation and transversus abdominis release (PCSTAR) with the open anterior component separation (OACS) technique. OACS, first described by Ramirez et al. (Plast Reconstr Surg 86(3):519-526, 1990), has become an established technique for local myofascial advancement in abdominal hernia surgery. PCSTAR, described by Novitsky et al. (Am J Surg 204(5):709-716, 2012), is being used more frequently and is rapidly becoming the technique of choice in complex ventral hernia repair. METHODS: Analysis was conducted according to PRISMA guidelines. A systematic search of the MEDLINE, EMBASE and Pubmed databases was performed. Studies reporting exclusively on midline ventral hernia repair were reviewed. Studies describing PCSTAR were selected and compared to matched studies describing OACS. Meta-analysis was used to compare outcomes between the two-pooled groups. RESULTS: Seven studies describing 281 cases of PCSTAR for midline incisional hernia using a retromuscular mesh placement were identified. Six comparable studies describing 285 cases of OACS and retromuscular mesh placement were identified from the same search. Pooled analysis demonstrated a hernia recurrence rate of 5.7% (3.0-8.5) for PCSTAR and 9.5% (4.0-14.9) for OACS. Comparative analysis demonstrated no significant difference between hernia recurrence rate (p = 0.23). The use of bridging mesh was not significantly reduced by the use of PCSTAR (3.1%) when compared to ACS (7.5%) (p = 0.22). No significant difference was found in wound complication rates between PCSTAR and OACS, respectively, 'superficial' 10.9 vs 21.6% (p = 0.15); and 'deep' 9.5 vs 12.7% (p = 0.53). CONCLUSIONS: These data suggest PCSTAR have comparable outcomes to OACS. This analysis is limited by the lack of comparative studies and heterogenicity in the OACS group.

The Elderly are Less Likely to Receive Recommended Radical Radiotherapy for Non-small Cell Lung Cancer.

AIMS: The National Institute for Healthcare Excellence recommends continuous hyperfractionated, accelerated radiotherapy (CHART), concurrent chemoradiation (cCRT) and stereotactic ablative radiotherapy (SABR) for appropriate patients with non-small cell lung cancer (NSCLC), but these are not universally available in all UK radiotherapy centres. Reduced access to these treatments may be contributing to reduced survival, with the concern that elderly patients are less likely to receive guideline-recommended therapy (GRT). MATERIALS AND METHODS: We report a prospective, UK national study of patients treated with curative-intent radiotherapy for NSCLC over a 2 month period. Clinical oncologists in all UK radiotherapy centres were contacted and asked to complete a proforma on all patients treated with curative-intent radiotherapy. RESULTS: Three hundred and seventeen records were returned from 82% of centres. Only 49% (95% confidence interval 43-55%) of patients received the GRT for their tumour type. Patients aged 70 years or over were less likely to access GRT than those under 70 years (40% compared with 60%, P = 0.001), both as a result of clinicians offering therapy less frequently (52% compared with 65%, P = 0.03) and a higher refusal of therapy (22% versus 8%, P = 0.02). A reluctance to travel to a different centre was a key component of these decisions. SABR was delivered to only 52% of suitable patients, mainly because it was not available in the local centre. CONCLUSIONS: In this study of UK curative-intent radiotherapy practice, a lack of local access seems to limit uptake of advanced radiotherapy techniques such as SABR, especially for patients aged over 70 years.

Outcome of a screening programme for the prevention of neonatal invasive early-onset group B Streptococcus infection in a UK maternity unit: an observational study.

BACKGROUND: Against a background of failure to prevent neonatal invasive early-onset group B Streptococcus infections (GBS) in our maternity unit using risk-based approach for intrapartum antibiotic prophylaxis, we introduced an antenatal GBS carriage screening programme to identify additional women to target for prophylaxis. OBJECTIVES: To describe the implementation and outcome of an antepartum screening programme for prevention of invasive early-onset GBS infection in a UK maternity unit. DESIGN: Observational study of outcome of screening programme (intervention) with comparison to historical controls (preintervention). SETTING: Hospital and community-based maternity services provided by Northwick Park and Central Middlesex Hospitals in North West London. PARTICIPANTS: Women who gave birth between March 2014 and December 2015 at Northwick Park Hospital. METHODS: Women were screened for GBS at 35-37 weeks and carriers offered intrapartum antibiotic prophylaxis. Screening programme was first introduced in hospital (March 2014) and then in community (August 2014). Compliance was audited by review of randomly selected case records. Invasive early-onset GBS infections were defined through GBS being cultured from neonatal blood, cerebrospinal fluid or sterile fluids within 0-6 days of birth. MAIN OUTCOME: Incidence of early-onset GBS infections. RESULTS: 6309 (69%) of the 9098 eligible women were tested. Screening rate improved progressively from 42% in 2014 to 75% in 2015. Audit showed that 98% of women accepted the offer of screening. Recto-vaginal GBS carriage rate was 29.4% (1822/6193). All strains were susceptible to penicillin but 11.3% (206/1822) were resistant to clindamycin. Early onset GBS rate fell from 0.99/1000 live births (25/25276) in the prescreening period to 0.33/1000 in the screening period (Rate Ratio=0.33; p=0.08). In the subset of mothers actually screened, the rate was 0.16/1000 live births (1/6309), (Rate Ratio=0.16; p<0.05). CONCLUSIONS: Our findings confirm that an antenatal screening programme for prevention of early-onset GBS infection can be implemented in a UK maternity setting and is associated with a fall in infection rates.