Localized Adherence Research Articles

Evaluation of Local Drug Delivery and Adherence Clubs for Stable Patients in South Africa

South Africa has the largest HIV treatment effort of any country and is struggling with over-burdened clinics and low retention in care and adherence

Influence Of Hotel Enterprises’ Social Cultural Practices On Community Empowerment Along The Coastal Tourism Circuit In Kenya

The study sought to assess the influence of socio-cultural practices on community empowerment along the coastal tourism circuit in Kenya. Data was obtained from 210 respondents who included hotel managers, employees from the local community, suppliers of goods and services to the enterprises including beach operators as well as civic leaders from Mombasa, Kwale and Kilifi counties. Hotel managers, employees, suppliers and beach operators completed a self administered questionnaire while civic leaders were interviewed. Results showed that socio-cultural practices adopted by the hotel enterprises influenced community empowerment, the influence of promotion of local heritage being significant. At the same time, it was illustrated that social innovation partially mediates the influence of the practices on community empowerment. Based on the findings, the study recommends enhanced adoption of elements of preservation of local culture and adherence to legal frame work to improve on the influence of socio-cultural practices on community empowerment.  Lastly, it recommends enhanced adoption of elements of social innovation so as to improve its mediating effect.

Development of a globally optimised model of the cerebral arteries

The cerebral arteries are difficult to reproduce from first principles, featuring interwoven territories, and intricate layers of grey and white matter with differing metabolic demand. The aim of this study was to identify the ideal configuration of arteries required to sustain an entire brain hemisphere based on minimisation of the energy required to supply the tissue. The 3D distribution of grey and white matter within a healthy human brain was first segmented from magnetic resonance images. A novel simulated annealing algorithm was then applied to determine the optimal configuration of arteries required to supply brain tissue. The model was validated through comparison of this ideal, entirely optimised, brain vasculature with the structure and properties of real arteries. This analysis established that the human cerebral vasculature is highly optimised; closely resembling the most energy efficient arrangement of vessels. In addition to local adherence to fluid dynamical optimisation principles, the optimised vasculature reproduced expected brain perfusion territories, featuring well-defined boundaries between anterior, middle and posterior regions. This validated brain vascular model and algorithm can be used for patient-specific modelling of stroke and cerebral haemodynamics, identification of sub-optimal conditions associated with vascular disease, and optimising vascular structures for tissue engineering applications and artificial organ design.

Automated data extraction and report analysis in computer-aided radiology audit: practice implications from post-mortem paediatric imaging

To determine local departmental adherence to the paediatric post-mortem magnetic resonance imaging (MRI) protocols, using a customised automated computational approach. A retrospective review of 460 whole-body post-mortem MRI examinations performed at Great Ormond Street Hospital for Children over a 5.5-year period was assessed for adherence to a full or abbreviated imaging sequence protocol. A simple computer program was developed to batch process DICOM (digital imaging and communications in medicine) files, extracting imaging sequence details, followed by natural language processing (NLP) of authorised reports to automate information extraction of diagnostic image quality. The program was able to extract study parameters from the entire dataset (approximately 80 GB of data) in a few hours, and retrieve information on diagnostic image quality using NLP with an overall diagnostic accuracy for data extraction of 96.7% (445/460, 95% confidence interval [CI]: 94.7-98%). The full imaging protocol was adhered to in 305/460 (66.3%) cases, and an abbreviated protocol in 140/460 (30.4%) cases. Overall, 423/460 (91.9%) of studies were of diagnostic quality. These included 298/305 (97.7%) of the full protocol, 111/140 (79.3%) of the abbreviated protocol. In only five cases were the examinations non-diagnostic for all body systems, all of whom weighed <100 g (24.7-72 g) and imaged using the abbreviated protocol. The present study demonstrated a successful application of an automated approach for data collection for audit and quality assessment purposes using paediatric post-mortem imaging as a specific example. Re-audit of these data following change implementation will be straightforward now that the automated workflow is clearly established.

Diversity of strategies used by atypical enteropathogenic Escherichia coli to induce attaching and effacing lesion in epithelial cells.

This study aimed to characterize 82 atypical enteropathogenic Escherichia coli (aEPEC) isolates, obtained from patients with diarrhea in Brazil, regarding their adherence patterns on HeLa cells and attaching and effacing (AE) lesion pathways. The adherence and fluorescence-actin staining (FAS) assays were performed using HeLa cells. AE lesion pathways were determined through the detection of tyrosine residue 474 (Y474) phosphorylation in the Tir protein, after its translocation to host cells, and by PCR assays for tir genotyping and detection of Tir-cytoskeleton coupling protein (tccP) genes. Regarding the adherence pattern, determined in the presence of d-mannose, 12 isolates (14.6 %) showed the localized adherence (LA)-like pattern, 3 (3.7 %) the aggregative adherence pattern and 4 (4.9 %) a hybrid LA/diffuse adherence pattern. In addition, 36 (43.9 %) isolates displayed an undefined adherence, and 26 (31.7 %) were non-adherent (NA), while one (1.2 %) caused cell detachment. Among the 26 NA aEPEC isolates, 11 showed a type 1 pilus-dependent adherence in assays performed without d-mannose, while 15 remained NA. Forty-eight (58.5 %) aEPEC were able to trigger F-actin accumulation underneath adherent bacteria (FAS-positive), which is an important feature of AE lesions. The majority (58.3 %) of these used the Tir-Nck pathway, while 39.6 % may use both Tir-Nck and Tir-TccP pathways to induce AE lesions. Our results reveal the diversity of strategies used by aEPEC isolates to interact with and damage epithelial host cells, thereby causing diarrheal diseases.

Using the Pharmaceutical Collection Database to identify patient adherence to oral hypoglycaemic medicines.

INTRODUCTION Poor adherence to oral hypoglycaemic medicines is a key contributor to therapy failure and sub-optimal glycaemic control among people with type 2 diabetes. It is unclear how commonly non-adherence to oral hypoglycaemics occurs in the general population. This information is essential to design and implement local adherence strategies. AIM This study aimed to determine levels of sub-optimal adherence and identify patient groups who may need additional adherence support. METHODS The dispensing data of 340,283 patients from one District Health Board was obtained from the Pharmaceutical Collection Database for the period 2008-15. Of these, 12,405 patients received oral hypoglycaemic therapy during the study period. The proportion of days covered (PDC) was calculated for patients with complete data and a PDC value of ≥80% was used to indicate sufficient adherence. Patient demographics (gender, ethnicity, age, socioeconomic status) and therapy type (mono- or combination) were described. RESULTS Overall, 54.5% of the patients were found to have a PDC of <80% and so were considered non-adherent. Non-adherence was significantly higher in patients receiving combination oral hypoglycaemic therapy than monotherapy; in male patients; in New Zealand Māori patients; and in patients with higher socioeconomic deprivation. DISCUSSION In the study region, non-adherence to oral hypoglycaemic medicines was significant and widespread. Identification of such patients is important so that strategies to enhance adherence can be implemented. Prescribers need to be encouraged to optimise monotherapy before the addition of another oral hypoglycaemic, and adherence support services should be offered not only to older patients.

Distribution of the pilS gene in Escherichia coli pathovars, its transfer ability and influence in the typical enteropathogenic E. coli adherence phenotype

Typical enteropathogenic Escherichia coli strains (tEPEC) cause attaching/effacing lesions in eukaryotic cells and produce the bundle-forming pilus (BFP), which interweaves and aggregates bacteria, resulting in the localized adherence (LA) pattern on eukaryotic cells. Previously, we identified tEPEC strains (serotype O119:H6) that exhibited LA simultaneously with an aggregative adherence (AA)-like pattern (LA/AA-like+). Remarkably, AA is characteristically produced by strains of enteroaggregative E. coli (EAEC), another diarrheagenic E. coli pathovar. In one LA/AA-like + strain (Ec404/03), we identified a conjugative plasmid containing the pil operon, which encodes the Pil fimbriae. Moreover, a pil operon associated with an AA pattern and plasmid transfer had been previously described in the EAEC C1096 strain. In this study, we investigated the occurrence of the two pilS alleles (pilSEc404 and pilSC1096) in tEPEC strains of different serotypes, origins and years of isolation. We also examined the potential relationship of pilS with the AA-like phenotype, its ability to be transferred by conjugation, and occurrence among strains of the other E. coli pathovars. The pilS alleles were found in 90 (55.2%) of 163 tEPEC strains, with pilSEc404 occurring more often (30.7%) than pilSC1096 (25.1%). About 21 tEPEC serotypes carried pilS. The pilS alleles were found in tEPEC strains from Chile, Peru and different Brazilian cities, with the oldest strain being isolated in 1966. No absolute correlation was found between the presence of pilS and the AA-like pattern. Conjugative pilS transfer was detected in 26.2% of pilSEc404+ strains and in 65.1% of pilSC1096+ strains, but only pilSEc404+ transconjugants were AA-like+, thus suggesting that the latter allele might need a different genetic background to express this phenotype. pilS was found in all other E. coli pathovars, where it was most prevalent in enterotoxigenic E. coli. More studies are needed to understand the mechanisms involved in the regulation of Pil expression and production.

Blood on board: The development of a prehospital blood transfusion program in a Canadian helicopter emergency medical service.

Prehospital blood transfusion has been adopted by many civilian helicopter emergency medical services agencies, and early outcomes are positive. The Shock Trauma Air Rescue Society operates six bases in Western Canada and started a blood on board process in 2013 in Regina that has expanded to all bases. Two units of O negative packed red blood cells are carried on every mission. We describe the processes and standard work ensuring safe storage, administration, and stewardship of this important resource. The packed red blood cells are stored in an inexpensive, reusable temperature controlled cooler at 1°C-6°C. Close collaboration with local transfusion services and adherence to Canadian transfusion standards contributes to safety and sustainability. From October 1, 2013 to October 10, 2017, the Shock Trauma Air Rescue Society administered blood to 431 patients. Of this total, 62.9% received blood carried on our aircraft. A total of 463 blood box units were administered, and the majority of patients (69.0%) received both units. Blood used in Calgary, Alberta was 100% traceable, and only 1.2% of total units dispensed was wasted. The vast majority of unused units were returned to circulation. We describe the process to set up and monitor a prehospital blood transfusion program. Our standard work and stewardship processes minimize wastage of blood while keeping it readily available for our critically ill and injured patients.

Patterns in breast cancer staging imaging: Are we choosing wisely?

51 Background: The American Society of Clinical Oncology’s Choosing Wisely guidelines recommend no staging imaging in early stage breast cancer (ESBC) patients with low risk of metastasis, as it is potentially harmful and provides no survival benefit. This study evaluates local adherence to this recommendation and identifies factors contributing to unnecessary staging imaging. Methods: This retrospective cohort study included patients with AJCC stage 0-II BC diagnosed from 2013-2015 at a single-site, academic medical center. Data was abstracted from chart review. Imaging included computed tomography, positron emission tomography, or bone scans. Imaging for documented symptoms was considered appropriate. Abstracted patient data included demographics, medical oncologist, and clinical characteristics. To evaluate factors influencing inappropriate screening imaging, risk ratios (RR) and corresponding 95% confidence intervals (CI) were estimated using generalized linear models with a log link and Poisson distribution with robust variance estimates. Results: Of the 872 ESBC patients, 262 (30%) underwent staging imaging. Median diagnosis age of patients receiving imaging was 55 (IQR 48-63) compared to 60 (IQR 52-68) for patients with no or appropriate imaging. Risk of inappropriate screening imaging was increased for patients who were younger (RR 0.98, 95% CI 0.97-0.98), had triple negative disease vs any hormone receptor positive (RR 2.98, 95% CI 2.25-3.95), had higher stage BC (I vs. 0, RR 3.58, 95% CI 2.05-6.25; II vs. 0, RR 10.86, 95% CI 6.43-18.33), and did not have Medicare insurance (RR 1.52, 95% CI 1.22-1.89). Rates of imaging did not vary by race (non-white vs. white: RR 0.98, 95% CI 0.78-1.23). For medical oncologists with at least 15 patients, prevalence of inappropriate imaging varied from 26-68%. Conclusions: A substantial proportion of ESBC patients received unnecessary and potentially harmful staging imaging inconsistent with guidelines. Staging imaging was associated with patient demographic and clinical characteristics related to increased recurrence risk, suggesting a need for further physician education about the low-risk nature of this ESBC population to ensure high value oncologic care.

Does Finance Make Us Less Social?

Informal risk sharing within social networks and formal financial contracts both enable households to manage risk. We find that financial contracting reduces participation in social networks. Specifically, increased crop insurance usage decreased local religious adherence and congregation membership in agricultural communities. Our identification utilizes the Federal Crop Insurance Reform Act of 1994 that doubled crop insurance usage nationally within a year, although changes in usage varied across counties. Difference-in-Difference and Spatial First Difference tests, with urban and neighboring counties as respective control groups, confirm that households substituted insurance for religiosity. This substitution was associated with reductions in crop diversification and crop yields, indicating an increase in moral hazard.

Distribution of Major Pilin Subunit Genes Among Atypical Enteropathogenic Escherichia coli and Influence of Growth Media on Expression of the ecp Operon.

Atypical enteropathogenic Escherichia coli (aEPEC) strains are unable to produce the bundle-forming pilus (BFP), which is responsible for the localized adherence pattern, a characteristic of the pathogenicity of typical EPEC strains. The lack of BFP in aEPEC strains suggests that other fimbrial or non-fimbrial adhesins are involved in their adhesion to the host cells. The aim of this study was to investigate the distribution of major subunit fimbrial genes known to be important adherence factors produced by several E. coli pathotypes in a collection of 72 aEPEC strains. Our results demonstrate that a high percentage (94–100%) of aEPEC strains harbored ecpA, fimA, hcpA, and lpfA fimbrial genes. Other fimbrial genes including pilS, pilV, sfpA, daaC, papA, and sfa were detected at lower frequencies (1–8%). Genes encoding fimbrial subunits, which are characteristic of enteroaggregative E. coli or enterotoxigenic E. coli were not found. No correlation was found between fimbrial gene profiles and adherence phenotypes. Since all aEPEC strains contained ecpA, the major pilin gene of the E. coli common pilus (ECP), a subset of ecpA+ strains was analyzed for transcription of ecpRABCDE and production of ECP upon growth in three different culture conditions at 37°C. Transcription of ecpRABCDE occurred in all conditions; however, ECP production was medium dependent. In all, the data suggest that aEPEC strains are highly heterogeneous in terms of their fimbrial gene profiles. Despite lacking BFP production, other mechanisms of cell adherence exist in aEPEC strains to ensure host colonization, e.g., mediated by other prevalent pili such as ECP. Moreover, the production of ECP by aEPEC strains might be influenced by yet unknown post-transcriptional factors.

Effects of static magnetic fields on the enteropathogenic Escherichia coli

This study reports the effects of exposing cells of the prototypical enteropathogenic Escherichia coli (EPEC) strain E2348/69 to static magnetic fields (SMF) of varying intensities to observe their capacity to autoaggregate and the effect on cell adherence. The results showed that bacteria exposure over the course of 5 min to an intensity of 53 mT reduced autoaggregation by 28%. However, with intensities of up to 100 mT with the same exposure time, bacteria autoaggregation was reduced by approximately 50%; and after 30 min at the same intensity, it was indistinguishable from that observed in a non-autoaggregative strain. Furthermore, it was observed that SMF treatment also modified the typical localized adherence pattern of EPEC E2348/69. The observed effects are not related to bacteria damage. The above was confirmed because, after a 107 mT SMF treatment over the course of 30 min, cell viability and membrane permeability were the same to that observed in untreated controls. The obtained results suggest that the SMF effect on the E2348/69 EPEC strain alters the expression of the bundle-forming pilus (BFP), due to the fact that the same strain without the EPEC adherence factor plasmid that encodes the BFP operon was unable to autoaggregate. Electron microscopic analyses revealed structural differences between cells exposed to SMF with respect to untreated controls. In conclusion, the SMF treatment of 107 mT for 30 min reduced EPEC E2348/69 autoaggregation and modified its adherence pattern, with both events likely being associated with changes in BFP expression. Bioelectromagnetics. 38:570-578, 2017. © 2017 Wiley Periodicals, Inc.

311 - An Evidence-Based Study: Evaluating the Management of Acute Heart Failure in the Gaza-Strip Hospitals

Introduction: Acute heart failure (AHF) is a life-threatening medical condition requiring urgent evaluation and treatment. This is the first clinical audit to evaluate the adherence of clinicians to international guidelines for management of AHF. Hypothesis: Development of local guidelines and adherence to them by clinicians will improve quality of care and ensure patient safety. Methods: This was a retrospective clinical audit conducted from January to December 2016. Two-hundred files of patients admitted to Nasser Hospital (n = 74) and Al-Shifaa Hospital (n = 126) were reviewed and compared to the European Society of Cardiology (ESC) Guidelines 2016. Results: The mean age of our sample was 66 ± 13 years. Fifty percent of patients were females and 96% had co-morbidities including hypertension, DM and heart disease. Shockingly vital signs were poorly documented (51% temperature, 59% pulse rate, 71.5% respiratory rate and 13% blood pressure) and SpO2 in only 69.5%. From the available data, at time of presentation, 40% had a high blood pressure, 37.7% had an SpO2 < 90%, 50.5% were anemic and 33% had leukocytosis. ECG, chest x-ray and echocardiography were done in 94.5%, 48.5% and 45%, respectively. Creatinine and urea levels were obtained in 93.5% and 89% with elevated values observed in 45.5% and 96.6%, respectively. Electrolytes (Na+ and K+) were measured in 63% of cases, glucose level in 88% but only 10% had arterial blood gases measured and 2.5% TSH level. It was found that 21.4% had hyperkalemia and 77.3% had hyperglycemia. Cardiac troponins were only done in 5.5% while 66.5% of patients had CKMB measured and BNP level wasn't utilized at all. Although 37.7% of patients had an SpO2 < 90%, it was surprising that only 12.5% received oxygen therapy. Intravenous furosemide was used in 69% and opiates were only administered to 30%. Vasodilators were given to 46.5% where systolic blood pressure was > 90 mmHg in 89.1% of them. Beta blockers (BB) were used in 57% (70.2% bisoprolol, 29.8% carvedilol). It was noted that BB were given to 2 hypotensive patients, which is not consistent with ESC guidelines. Digoxin 0.25 mg was given in 28.5% of which 53.4% had atrial fibrillation. Venous thromboembolism prophylaxis was administered to 70%. Conclusions: The results of this audit reflect the fact that the management of AHF does not comply with the ESC guidelines. This could be attributed to the lack of local guidelines and unawareness of international guidelines. Furthermore, the poor medical record and registry systems cause loss of data and physician orders which in turn causes more deviation from the recommended guidelines. Therefore, there is an urgent need for the development of local guidelines as well as promotion of knowledge of evidence-based practice among clinicians. In addition, the current documentation system should be improved as soon as possible to facilitate the process of evaluating the clinical practice in future.

Antibiotic Resistance and Virulence Phenotypes of Recent Bacterial Strains Isolated from Urinary Tract Infections in Elderly Patients with Prostatic Disease.

Acute bacterial prostatitis is one of the frequent complications of urinary tract infection (UTI). From the approximately 10% of men having prostatitis, 7% experience a bacterial prostatitis. The purpose of this study was to investigate the prevalence of uropathogens associated with UTIs in older patients with benign prostatic hyperplasia and to assess their susceptibility to commonly prescribed antibiotics as well as the relationships between microbial virulence and resistance features. Uropathogenic Escherichia coli was found to be the most frequent bacterial strain isolated from patients with benign prostatic hyperplasia, followed by Enterococcus spp., Enterobacter spp., Klebsiella spp., Proteus spp., Pseudomonas aeruginosa, and Serratia marcescens. Increased resistance rates to tetracyclines, quinolones, and sulfonamides were registered. Besides their resistance profiles, the uropathogenic isolates produced various virulence factors with possible implications in the pathogenesis process. The great majority of the uropathogenic isolates revealed a high capacity to adhere to HEp-2 cell monolayer in vitro, mostly exhibiting a localized adherence pattern. Differences in the repertoire of soluble virulence factors that can affect bacterial growth and persistence within the urinary tract were detected. The Gram-negative strains produced pore-forming toxins—such as hemolysins, lecithinases, and lipases—proteases, siderophore-like molecules resulted from the esculin hydrolysis and amylases, while Enterococcus sp. strains were positive only for caseinase and esculin hydrolase. Our study demonstrates that necessity of investigating the etiology and local resistance patterns of uropathogenic organisms, which is crucial for determining appropriate empirical antibiotic treatment in elderly patients with UTI, while establishing correlations between resistance and virulence profiles could provide valuable input about the clinical evolution and recurrence rates of UTI.

“No Ku Klux Klan for Kern”

The Ku Klux Klan saw a rapid rise in Kern County, California, in 1921 but disintegrated in 1922. Local newspapers decried the Klan’s vigilante violence; a diligent district attorney pursued and prosecuted those involved; and the local press and the court cases revealed members’ identities. The ensuing backlash quickly neutralized the Klan in Kern County. The revealed identities enabled the author to profile local KKK adherents. The subsequent career paths of key members and their opponents confirm the shift of public opinion against the Klan despite its public relations efforts.

Self-Conjugation of the Enteropathogenic Escherichia coli Adherence Factor Plasmid of Four Typical EPEC Isolates.

The enteropathogenic Escherichia coli (EPEC) adherence factor plasmid (pEAF) encodes the proteins involved in the biogenesis of the bundle-forming pilus (BFP), a key virulence factor that mediates microcolony formation and the localized adherence phenotype on the surface of the host enterocytes. The presence or absence of this plasmid defines typical EPEC (tEPEC) and atypical EPEC (aEPEC), respectively. Although lateral transfer of pEAF has been evidenced by phylogenetic studies, conjugal transfer ability has been experimentally established only for two pEAF plasmids from strains isolated in the late 60s. In the present work, we tested the self-conjugation ability of four pEAF plasmids from tEPEC strains isolated between 2007 and 2008 from children in Peru and the potential of aEPEC to receive them. A kanamycin resistance cassette was inserted into donor pEAF plasmids in order to provide a selectable marker in the conjugation experiments. Two aEPEC isolated from the same geographic region were used as recipient strains along with the laboratory E. coli DH5α strain. Here we show that the four pEAF plasmids tested are self-conjugative, with transfer frequencies in the range of 10−6 to 10−9. Moreover, the generation of aEPEC strains harboring pEAF plasmids provides valuable specimens to further perform functional studies.

Serotypes, virulence markers and cell invasion ability of Shiga toxin-producing Escherichia coli strains isolated from healthy dairy cattle.

The occurrence of virulence markers, serotypes and invasive ability were investigated in Shiga toxin-producing Escherichia coli (STEC) isolated from faecal samples of healthy dairy cattle at Rio de Janeiro State, Brazil. From 1562 stx-positive faecal samples, 105 STEC strains were isolated by immuno-magnetic separation (IMS) or plating onto MacConkey agar (MC) followed by colony hybridisation. Fifty (47·6%) strains belonged to nine serotypes (O8:H19, O22:H8, O22:H16, O74:H42, O113:H21, O141:H21, O157:H7, O171:H2 and ONT:H21). The prevalent serotypes were O157:H7 (12·4%), O113:H21 (6·7%) and O8:H19 (5·7%). Virulence genes were identified by polymerase chain reaction (PCR). E-hlyA (77·1%) was the more prevalent virulence marker, followed by espP (64·8%), saa (39%), eae (24·8%) and astA (21·9%). All O157:H7 strains carried the γ (gamma) variant of the locus of enterocyte effacement (LEE) genes and the stx2c gene, while the stx1/stx2 genotype prevailed among the eae-negative strains. None of the eae-positive STEC produced the localized adherence (LA) phenotype in HEp-2 or Caco-2 cells. However, intimate attachment (judged by the fluorescent actin staining test) was detected in some eae-positive strains, both in HEp-2 (23·1%) and in Caco-2 cells (11·5%). Most strains (87·5%) showed 'peripheral association' (PA) adherence phenotype to undifferentiated Caco-2 cells. Twenty-five (92·6%) of 27 strains invaded Caco-2 cells. The highest average value of invasion (9·6%) was observed among the eae-negative bovine strains from serotypes described in human disease. Healthy dairy cattle is a reservoir of STEC carrying virulence genes and properties associated with human disease. Although reports of human disease associated with STEC are scarce in Brazil, the colonization of the animal reservoir by potentially pathogenic strains offers a significant risk to our population.

PWE-120 Stricter Adherence to Surveillance Colonoscopy Guidelines for Colorectal Adenomas Could Result in Reduced Burden on Endoscopy Services

Introduction International guidelines recommend repeating surveillance colonoscopy in patients with colonic adenomas. We aimed to study local adherence to such guidelines. Methods Patients diagnosed with colonic adenomas between March and August 2008 were enrolled. Surveillance colonoscopy following adenoma removal was audited against the British Society of Gastroenterology guidelines: repeat in 5 years or no follow-up in low risk patients, repeat in 3 years in intermediate risk patients and repeat in 1 year in high risk patients. Results 165 patients (61.8% males; mean age 62.1) were risk stratified as per guidelines. 95 patients (57.6%) were low risk, 61 (37%) intermediate risk, and 9 (5.4%) high risk. In the low risk group, 43 patients (45%) had surveillance either ≥5 years or never and 52 (55%) had a shorter follow up. In the intermediate risk group, 9 (14.8%) patients had surveillance at 3 years, 28 (45.9%) patients before 3 years, 8 (13.1%) patients after 3 years and 16 (26.2%) patients had no follow up colonoscopy. In the high risk group, 5 (55.6%) patients had surveillance at 1 year, 1 (11.1%) patient before 1 year, 2 (22.2%) patients after 1 year and 1 (11.1%) patient had no follow up colonoscopy. 2 patients (1.2%) were diagnosed with interval colon cancer in the same year as the index colonoscopy. Conclusion Guideline non-adherence was noted in 65.5%, mainly due to too aggressive surveillance (49.1% early colonoscopies), increasing burden on endoscopy services. Late colonoscopies (6.1%) or no follow up colonoscopies (10.3%) were not the cause for interval cancers. Disclosure of Interest None Declared

PTU-125 Laboratory Investigations for Patients Meeting Diagnostic Criteria for Irritable Bowel Syndrome: Are We Meeting the Standards?

Introduction Alongside a thorough clinical assessment NICE clinical guideline 61 recommends that patients meeting diagnostic criteria for irritable bowel syndrome (IBS), as defined by the Rome III criteria, should undergo laboratory testing for inflammation (C-reactive peptide (CRP) and plasma viscosity (PV) or erythrocyte sedimentation rate (ESR)), full blood count (FBC) and antibody testing for coeliac disease to exclude non-organic pathology.1 Faecal calprotectin is a reliable and cost effective adjuvant test to help differentiate between functional and inflammatory bowel disease (IBD).2,3 Our aim was to assess local adherence to NICE guidelines on investigating patients who meet diagnostic criteria for IBS. Methods As part of a wider study into the use of faecal calprotectin as a diagnostic tool within Gloucestershire Hospitals NHS Foundation Trust, we interrogated clinic letters, endoscopy reports and pathology results for patients in whom a negative ( Results Of the 148 patients (age range: 16–81, median age: 35; 72% female) who satisfied inclusion criteria, 63.5% (n = 94) had not undergone at least one of the recommended laboratory tests around the time of faecal calprotectin measurement. PV/ESR had not been checked in a majority (54.1%). Notably, 7.4% of patients had never had coeliac serology checked, 72.7% of whom presented with a change in bowel habit. Conclusion Although clear guidance exists for the investigation of patients meeting diagnostic criteria for IBS and use of faecal calprotectin as a diagnostic tool, insufficient essential accessory investigations are being completed. This risks conditions such as IBD, gastrointestinal cancer and coeliac disease being misdiagnosed as IBS with significant implications for delays in management and ongoing avoidable morbidity. We are reviewing measures to improve local adherence to NICE guidance, and call on other Trusts nationally to reflect on their own practice. References 1 Irritable bowel syndrome in adults: diagnosis and management. NICE guidelines [CG61]. Published: February 2008. 2 Konikoff MR, Denson LA. Role of faecal calprotectin as a biomarker of intestinal inflammation in inflammatory bowel disease. Inflammatory Bowel Diseases 2006;12(6):524–34. 3 Faecal calprotectin diagnostic tests for inflammatory diseases of the bowel. NICE diagnostics guidance [DG11]. Published: October 2013. Disclosure of Interest None Declared

Collaborative Pediatric Bone Tumor Program to Improve Access to Specialized Care: An Initiative by the Lebanese Children's Oncology Group.

BackgroundChildren with malignant bone tumors have average 5-year survival rates of 60% to 70% with current multimodality therapy. Local control modalities aimed at preserving function greatly influence the quality of life of long-term survivors. In developing countries, the limited availability of multidisciplinary care and limited expertise in specialized surgery and pediatric radiation therapy, as well as financial cost, all form barriers to achieving optimal outcomes in this population.MethodsWe describe the establishment of a collaborative pediatric bone tumor program among a group of pediatric oncologists in Lebanon and Syria. This program provides access to specialized local control at a tertiary children’s cancer center to pediatric patients with newly diagnosed bone tumors at participating sites. Central review of pathology, staging, and treatment planning is performed in a multidisciplinary tumor board setting. Patients receive chemotherapy at their respective centers on a unified treatment plan. Surgery and/or radiation therapy are performed centrally by specialized staff at the children’s cancer center. Cost barriers were resolved through a program development initiative led by St Jude Children’s Research Hospital. Once program feasibility was achieved, the Children’s Cancer Center of Lebanon Foundation, via fundraising efforts, provided continuation of program-directed funding.ResultsFindings over a 3-year period showed the feasibility of this project, with timely local control and protocol adherence at eight collaborating centers. We report success in providing standard-of-care multidisciplinary therapy to this patient population with complex needs and financially challenging surgical procedures.ConclusionThis initiative can serve as a model, noting that facilitating access to specialized multidisciplinary care, resolution of financial barriers, and close administrative coordination all greatly contributed to the success of the program.