Standard Practice Research Articles

CIRSE Standards of Practice on Transjugular Intrahepatic Portosystemic Shunts.

Proposed in the early 1980s as a solution for managing complications of portal hypertension, the percutaneous creation of transjugular intrahepatic portosystemic shunt has consistently gained a central role. Increasingly lower complication rates have been observed thanks to improvements in both technologies and the skills of interventional radiologists. This document is aimed at interventional radiologists and provides best practice recommendations for transjugular intrahepatic portosystemic shunt creation, describing patient selection, intraprocedural management and follow-up, in addition to recommendations in paediatric settings. The CIRSE Standards of Practice Committee established a writing group consisting of seven European clinicians with recognised expertise in the creation of transjugular intrahepatic portosystemic shunt. The writing group reviewed the existing literature performing a pragmatic evidence search using PubMed to select relevant publications in the English language and involving human subjects, preferably published from 2009 to 2024. The final recommendations were developed by consensus. TIPS creation has an established role in the successful management of portal hypertension and its complications. This Standards of Practice document provides up-to-date recommendations for patient selection, materials, its safe performance, and follow-up with complications management.

A new perspective on diagnostic strategies concerning the potential of saliva-based miRNA signatures in oral cancer.

Oral cancer, the most prevalent cancer worldwide, is far more likely to occur after the age of forty-five, according to the World Health Organization. Although many biomarkers have been discovered over the years using non-invasive saliva samples, biopsies, and human blood, these biomarkers have not been incorporated into standard clinical practice. Investigating the function of microRNAs (miRNAs) in the diagnosis, aetiology, prognosis, and treatment of oral cancer has drawn more attention in recent years. Though salivary microRNA can act as a window into the molecular environment of the tumour, there are challenges due to the heterogeneity of oral squamous cell carcinoma (OSCC), diversity in sample collection, processing techniques, and storage conditions. The up and downregulation of miRNAs has been found to have a profound role in OSCC as it regulates tumour stages by targeting many genes. As a result, the regulatory functions of miRNAs in OSCC underscore their significance in the field of cancer biology. Salivary miRNAs are useful diagnostic and prognostic indicators because their abnormal expression profiles shed light on tumour behaviour and patient prognosis. In addition to their diagnostic and prognostic value, miRNAs hold promise as therapeutic targets for oral cancer intervention. The current review sheds light on the challenges and potentials of microRNA studies that could lead to a better understanding of oral cancer prognosis, diagnosis, and therapeutic intervention. Furthermore, the clinical translation of OSCC biomarkers requires cooperation between investigators, physicians, regulatory bodies, and business partners. There is much potential for improving early identification, tracking therapy response, and forecasting outcomes in OSCC patients by including saliva-based miRNAs as biomarkers.

The impact of diet on the inflammatory bowel disease course – a literature review

Introduction and Objective. Inflammatory bowel disease (IBD), including ulcerative colitis (UC) and Crohn’s disease (CD), is a chronic gastrointestinal disorder marked by relapsing symptoms. Current treatments mainly involve immunosuppressive therapies, which are effective but may have significant side effects. Diet as an adjunctive treatment is appealing due to its accessibility, low cost, and minimal adverse effects. This review explores the role of diet in managing IBD, focusing on dietary strategies during both active disease and remission. Methods. A literature review was conducted using PubMed and Google Scholar with search terms like "inflammatory bowel disease", "Crohn’s disease", "ulcerative colitis", "diet", "IBD treatment", "anti-inflammatory food" and related variations. Articles published within the last five years were prioritized. Brief description of the state of Knowledge. Ulcerative colitis and Crohn’s disease cause gastrointestinal inflammation. Crohn’s disease symptoms include abdominal pain, fistulas and rectal lesions, while UC is characterized by diarrhea, severe discomfort, and blood in the stool. Certain foods often exacerbate IBD symptoms. Proper nutrition during disease stages can improve patients’ quality of life. Diets high in processed foods, sugar, and red meat may increase IBD risk, while fiber and vitamin D3 are associated with fewer flare-ups. Regular malnutrition screening is essential for all IBD patients. Conclusions. Understanding the dietary components that influence inflammation in IBD could lead to better treatment outcomes and longer-lasting symptom relief. Integrating nutrition into personalized treatment strategies should become standard practice for managing IBD.

Systematic Review of AI-Assisted MRI in Prostate Cancer Diagnosis: Enhancing Accuracy Through Second Opinion Tools

Background: Prostate cancer is a leading cause of cancer-related deaths in men worldwide, making accurate diagnosis critical for effective treatment. Recent advancements in artificial intelligence (AI) and machine learning (ML) have shown promise in improving the diagnostic accuracy of prostate cancer. Objectives: This systematic review aims to evaluate the effectiveness of AI-based tools in diagnosing prostate cancer using MRI, with a focus on accuracy, specificity, sensitivity, and clinical utility compared to conventional diagnostic methods. Methods: A comprehensive search was conducted across PubMed, Embase, Ovid MEDLINE, Web of Science, Cochrane Library, and Institute of Electrical and Electronics Engineers (IEEE) Xplore for studies published between 2019 and 2024. Inclusion criteria focused on full-text, English-language studies involving AI for Magnetic Resonance Imaging (MRI) -based prostate cancer diagnosis. Diagnostic performance metrics such as area under curve (AUC), sensitivity, and specificity were analyzed, with risk of bias assessed using the Quality Assessment of Diagnostic Accuracy Studies (QUADAS-2) tool. Results: Seven studies met the inclusion criteria, employing various AI techniques, including deep learning and machine learning. These studies reported improved diagnostic accuracy (with AUC scores of up to 97%) and moderate sensitivity, with performance varying based on training data quality and lesion characteristics like Prostate Imaging Reporting and Data System (PI-RADS) scores. Conclusions: AI has significant potential to enhance prostate cancer diagnosis, particularly when used for second opinions in MRI interpretations. While these results are promising, further validation in diverse populations and clinical settings is necessary to fully integrate AI into standard practice.

An Economic Assessment of the EU–Japan Economic Partnership Agreement with Realistic Preference Utilization Rates

Abstract Recent years have seen an increased focus on the implementation of Preferential Trade Agreements (PTAs). While the number of PTAs has risen remarkably since early 2000, data on the utilization of preferential tariffs under these agreements point out that some businesses have not gained access to all the benefits that PTAs can provide. When utilization rates are low, the impact of the agreement will likely differ from what was anticipated by ex-ante economic research. This paper conducts a dynamic Computable General Equilibrium (CGE) analysis of the expected impact of the EU–Japan Economic Partnership Agreement and compares a scenario that includes realistic preference utilization data with a standard scenario where all tariff liberalization is assumed to be fully utilized by businesses. The results show considerable differences between the two scenarios and illustrate the need to make the inclusion of credible utilization data standard practice in the modelling of international trade.

Clinical utility of administering the WISC-V as standard practice in paediatric attention-deficit/hyperactivity disorder (ADHD) assessments in a public hospital and health system: a rapid review to inform clinical practice

ABSTRACT Objective The purpose of this rapid review is to appraise the current evidence-base to inform the development of a new assessment and diagnostic pathway for ADHD presentations in a public health paediatric department in Brisbane. We posited that the standardised WISC-V administration in all ADHD presentations regardless of cognitive indication was low-value, inefficient and burdensome for clinicians, children and their families. We wanted to find out if the literature supports this position. Method This review used PRISMA systematic methods to search two relevant databases (PUBMED, and Elsevier (ClinicalKey)). Search terms were used: (attention deficit hyperactivity disorder OR ADHD) AND (children) AND (assessment OR diagnosis) AND (Australia) AND (cognitive proficiency) OR (WISC). Results Search returned 286 full text journal articles, published between 2018 and 2023. Two hundred and sixty-two were removed to irrelevance, adult population, duplications, or focus on other paediatric mental health disorders. Following the application of exclusion criteria, 10 were reviewed at full text and four were ultimately included for contribution to this rapid review. Conclusions Neuropsychological testing if no cognitive query is indicated may confound the findings. This review provided the opportunity to improve clinical efficiency without compromising diagnostic accuracy.

The urban footprint of rural forced displacement

AbstractThe rapid growth of marginal settlements in the Global South, largely fueled by the resettlement of millions of internally displaced people (IDPs), underscores the urgent need for tailored housing solutions for these vulnerable populations. However, prevailing approaches have often relied on a one-size-fits-all model, overlooking the diverse socio-spatial realities of IDP communities. Drawing on a case study in Medellin, Colombia, where a significant portion of the population consists of forced migrants, this interdisciplinary study merges concepts from human geography and urban theory with computational methods in remote sensing and exploratory spatial data analysis. By integrating socio-spatial theory with quantitative analysis, we challenge the conventional housing paradigm and propose a novel framework for addressing the housing needs of IDPs. Employing a three-phase methodology rooted in Lefebvre’s theoretical framework on the production of space, including participatory mapping, urban morphology characterization, and similarity analysis, we identify distinct patterns within urban IDP settlements and advocate for culturally sensitive housing policies. Our analysis, focusing on Colombia, the country with the largest IDP population globally, reveals the limitations of standardized approaches and highlights the importance of recognizing and accommodating socio-cultural diversity in urban planning. By contesting standardized socio-spatial practices, our research aims not only to promote equality but also to foster recognition and inclusivity within marginalized communities.

RECENT DEVELOPMENTS IN ENDOVASCULAR THERAPY FOR CHRONIC SUBDURAL HEMATOMAS USING LIQUID EMBOLIC AGENTS

Chronic subdural hematomas (cSDH) remain a significant challenge in neurosurgery, particularly among the elderly. Recent advancements in endovascular therapy, specifically the use of non-adhesive embolic agents, have shown promise in improving outcomes for these patients. This presentation will delve into the latest developments and clinical evidence surrounding this innovative approach. The discussion will include findings from recent randomized trials that have evaluated the efficacy and safety of embolisation with non-adhesive agents, both as a standalone treatment and in conjunction with traditional surgical methods. Technical outcomes from these studies will be analyzed, highlighting key differences in patient recovery, complication rates, and long-term results between the combined and isolated approaches. One of the focal points of the presentation will be the technical nuances of performing embolisation, emphasizing the procedural intricacies and the choice of embolic materials. Comparative data will be presented to illustrate the benefits of non-adhesive agents over other embolisation methods, particularly in terms of reducing re-bleeding rates and minimizing invasive interventions. Additionally, we will explore future implications of widespread adoption of this technique, including its potential to alter standard care practices and improve patient prognoses. Projections will be made regarding the impact on healthcare resources, patient quality of life, and overall survival rates. The presentation aims to provide a comprehensive overview of the current state and future potential of endovascular therapy for cSDH, offering valuable insights for neurosurgeons and interventional radiologists seeking to enhance their therapeutic arsenal.

MS O06 - HPB The ORDEAL Study: A National Survey of Surgeon Operative Preferences for Resection of Duodenal Adenocarcinoma

Abstract Background Duodenal adenocarcinoma (DA) accounts for over 50% of all small bowel adenocarcinomas, however there is a paucity of data on outcomes, no UK guidelines for surgical management, and current national standards of practice are unknown. There is ongoing debate whether long-term survival, perioperative outcomes, resection margin, and lymph node yield differ between pylorus-preserving pancreaticoduodenectomy (PPPD) and classical PD (cPD) in proximal DA (D1/D2), and between PD and limited resection (LR) in distal DA (D3/D4). The study aimed to discern current standards of practice and identify underlying reasons for operative preferences for proximal and distal DA. Method An anonymised survey was included as part of the registration form for a wider multicentre retrospective study looking at outcomes following resection for proximal and distal DA on Google Forms®. The survey was distributed via direct surgeon email correspondence, weekly newsletters and surgical society endorsement by PSGBI. Responses were collected between February-June 2024 and responses were analysed with quantitative and qualitative (inductive thematic analysis) methods. Results Responses were received from 61 surgeons across 27 centres. For proximal DA, surgeons are more likely to consider a classical Whipple’s (93.4%) compared to PPPD (29.5%). For distal DA, surgeons are equally likely to consider LR (73.8%) as PD (classical Whipple’s -37.7%, PPPD - 41%). These preferences have mostly remained consistent over time. Key themes identified from thematic analysis included oncological considerations, morbidity, surgeon preference, tumour characteristics, standards of practice, patient factors and anatomical considerations, with the former two themes being the most prominent. Conclusion For proximal DA, cPD is preferred over PPPD and for distal DA, LR and PD are equally considered, with oncological and morbidity considerations largely influencing decision making. This qualitative data will be compared to actual practice following completion of the wider ORDEAL study to identify discrepancies in practice and possible effect on patient outcomes.

HPB SO46 - Risk Stratification for Acute Pancreatitis: A Retrospective Comparative Analysis between Glasgow-Imrie and BISAP Scoring Systems within a District General Hospital

Abstract Background Risk stratification for acute pancreatitis (AP) is an important tool in clinical decision making. The BISAP score has been validated to be a comparable risk prognostication tool to current models[1, 2]. Current trust practice is the Glasgow-Imrie score, which involves more invasive and non-routine investigations, resulting in an increased cost and labour burden. Additionally, a previous local audit demonstrated poor compliance with only 55% of admissions having a documented score, limiting utility and prognostication. By demonstrating non-inferiority, we aim to implement BISAP as the standard of practice with earlier severity assessment, improved patient experience and minimising unnecessary investigations. Method A retrospective analysis of 153 admissions with acute pancreatitis admitted to a single-site district general hospital over a 12-month period was performed, reviewing electronic patient records for documentation, observations and investigations. Both Glasgow-Imrie and BISAP scores were calculated within 48 and 24 hours of admission retrospectively and respectively. Descriptive statistics was used to summarise data and compare trends between both scores and the severity of acute pancreatitis, ICU admissions and mortality. Logistic regression was utilised to model the relationship between both systems and binary outcomes with area under the curve (AUC) and non-inferiority tests derived to determine efficacy. Results The cohort had a mean age of 57 ± 18.53 (52:48 male:female) with an average LOS of 7.25 ± 10.12 days. 6.54% had severe AP, 3.92% required ICU admisison and 3.26% mortality rate. The AUC value for both models was 0.868 in predicting severity (p<0.001) with Glasgow-Imrie performing better in predicting ICU admission (AUC 0.954 > 0.855, p<0.01) and BISAP outperforming Glasgow-Imrie in predicting mortality (AUC 0.903 > 0.867, p<0.01). Bootstrapping resampling demonstrated no significant difference between models in predicting severity (δAUC 0.0007, 95%CI -0.01181, 0.1167), ICU admission (δAUC 0.1010, 95%CI -0.0113, 0.2140) and mortality (δAUC -0.0366, 95%CI -0.0788, 0.0045). Conclusion Both the Glasgow-Imrie and BISAP scoring systems are accurate in predicting the severity of pancreatitis, ICU admission and mortality. The BISAP score is similar in prognostic accuracy to the Glasgow-Imrie score and is advantageous in being simpler to obtain in clinical practice with a higher rate of completeness. We recommend the BISAP score as a non-inferior, pragmatic risk stratification tool in acute pancreatitis.

EGS SO16 - Retrospective review of adherence of emergency theatres operation notes to Royal College of Surgeons in England Guidelines

Abstract Background Adherence to standardized operation note guidelines is crucial for ensuring patient safety and maintaining high standards of surgical practice. This study aims to evaluate the compliance of emergency theatre operation notes with the Royal College of Surgeons in England guidelines, identifying areas for improvement to enhance documentation practices. Method A retrospective review of 50 patients was conducted on operation notes from emergency theatres. The notes were assessed for adherence to the Royal College of Surgeons in England guidelines. Parameters evaluated included completeness of patient information, surgical procedure details, intraoperative findings, and postoperative instructions. Results There was good compliance in sections such as the name of the operative and assistance, operative findings, and closure. However, improvements are needed in sections such as problems encountered, anticipated blood loss, and the name of antibiotics used. Compliance can be improved by making the notes clearer and more comprehensive. Conclusion Our analysis suggests room for improvement in adherence to postoperative surgical note guidelines. We recommend adding further details such as the name of the scrub nurse, indication, to the operative notes. A postoperative checklist template has been devised to ensure adherence to guidelines and improve documentation practices.

Extravasation Identification and Management in Neonates and Pediatrics: A Cross Sectional Survey.

To explore current practice and guidelines surrounding the identification and management of extravasation injuries in Australian and New Zealand neonatal and pediatric settings. Between February and September 2023, an internet-based descriptive cross-sectional survey was distributed to Australian and New Zealand neonatal and pediatric clinicians using exponential nondiscriminative snowball sampling. Survey data domains included demographics, extravasation identification, management, local guidelines, and resources. Of the 141 responses, the majority of respondents were registered nurses (n = 96, 68.1%), with greater than 20 years of experience (n = 51, 36.2%). Over two-thirds of respondents had no extravasation identification and management training (n = 98, 69.5%). Half of the respondents (n = 70, 49.6%) reported that increased presentation of risk factors did not alter monitoring frequency. Extravasations were primarily associated with the hand and wrist region (n = 118, 43.7%). Maintenance fluids, antibiotics and parenteral nutrition accounted for extravasation events. Acute management practices (immediate cessation of infusion) showed consistency (n = 124, 87.9%), whereas varying degrees of adoption were observed for aspirating the residual fluid. The majority of respondents (n = 119, 84%) reported the absence of a formal grading scale for extravasation severity. Clinicians reported challenges and inconsistencies in neonatal and pediatric extravasation injury identification and management. This underscores the need for effective monitoring and identification, standardized management practices, and education to minimize the burdens of extravasation for patients, families, and the health care system.

Learning extreme vegetation response to climate drivers with recurrent neural networks

Abstract. The spectral signatures of vegetation are indicative of ecosystem states and health. Spectral indices used to monitor vegetation are characterized by long-term trends, seasonal fluctuations, and responses to weather anomalies. This study investigates the potential of neural networks in learning and predicting vegetation response, including extreme behavior from meteorological data. While machine learning methods, particularly neural networks, have significantly advanced in modeling nonlinear dynamics, it has become standard practice to approach the problem using recurrent architectures capable of capturing nonlinear effects and accommodating both long- and short-term memory. We compare four recurrent-based learning models, which differ in their training and architecture for predicting spectral indices at different forest sites in Europe: (1) recurrent neural networks (RNNs), (2) long short-term memory networks (LSTMs), (3) gated recurrent unit networks (GRUs), and (4) echo state networks (ESNs). While our results show minimal quantitative differences in their performances, ESNs exhibit slightly superior results across various metrics. Overall, we show that recurrent network architectures prove generally suitable for vegetation state prediction yet exhibit limitations under extreme conditions. This study highlights the potential of recurrent network architectures for vegetation state prediction, emphasizing the need for further research to address limitations in modeling extreme conditions within ecosystem dynamics.

HPB SO50 - A comprehensive review of clinical practice guidelines for managing hepatic adenoma

Abstract Background Hepatic adenoma(HCA) are increasingly diagnosed as incidentalomas. Clinical implications and management vary across and within the different types of Hepatic adenomas. Practice guidelines are needed, because of the many variation, diagnostic tools, and conservative and invasive management protocols. Therefore, our aim was to systematically search for available clinical practice guidelines on hepatic adenoma, critically appraise them, and compare management recommendations. Method Systematic literature search was performed by two investigators using appropriate prespecified search terms within the bibliographic databases of MEDLINE, EMBASE, and PubMed. All HCA guidelines published in peer-reviewed, and English language journals were eligible for inclusion. Clinical practice guidelines on HCA were analysed, compared, and critically appraised using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses recommendations (PRISMA) 2020 checklist. Results The literature search yielded unique 199 papers, 187 were excluded after screening of title/abstract, and 9 after full-text screening. Guidelines included were: (EASL; 2016, (ACG; 2014), (SBH; 2015),). There were no set standards in the assessment methods for grading and gravity of recommendations between guidelines. Observed differences were: (1) indications for biopsy; (2) advices on contraceptive pills and follow-up; (3) use of an lesion centred approach to HCA; (4) lack of adequate treatment recommendations of HCA in male population ; and (5) approach to HCA depending on subtype varaition on magnetic resonance imaging. Conclusion Recognising differences in recommendations can assist in formulating practice standards and identify needs for research.

Management of the Expected Difficult Airway with Planned One-Lung Ventilation: A Retrospective Analysis of 44 Cases.

Difficult airway management is essential in anesthesia practice. Particular challenges are posed to patients who require intraoperative one-lung ventilation. Specific guidelines for these scenarios have been lacking. The recent update of German guidelines incorporates recommendations for securing the airway in anticipated difficult airway scenarios in patients requiring one-lung ventilation. However, scientific data on this specific topic is rare. A retrospective analysis was conducted on adult patients undergoing thoracic surgery with one-lung ventilation from 2016 to 2021. During these years, the standard of practice has been in line with the now published guidelines. Patients with anticipated difficult airways were identified, and airway management strategies were analyzed. Among 3,197 anesthetic procedures, 44 cases involved anticipated difficult airways, primarily due to prior head and neck tumor treatment. Nasal bronchoscopic awake intubation followed by oral reintubation under videolaryngoscopic inspection and the use of bronchial blockers was the standard procedure. No severe complications were recorded, and one-lung ventilation was maintained successfully in all cases. The study highlights the challenges of managing difficult airways during thoracic surgery. Recommendations align with recent guidelines, emphasizing the importance of tailored approaches. The use of single-lumen tubes with bronchial blockers appears favorable over double-lumen tubes, offering comparable ventilation quality with reduced risks. Despite limitations, the study underscores the safety and efficacy of tailored airway management strategies during one-lung ventilation in patients with anticipated difficult airways. The presented approach offers patient safety and practicability. Further multicenter studies are warranted to validate these findings and refine clinical approaches.

An overview of cell salvage in orthopaedic hip and knee arthroplasty surgery.

Blood management is a critical aspect of patient care during surgical procedures. In the United Kingdom, there is a growing recognition of the need to integrate intraoperative cell salvage into blood management protocols, especially for invasive surgeries where significant blood loss is anticipated. While donated blood (allogeneic blood) is traditionally used in such cases, it carries risks and potential complications. Consequently, intraoperative cell salvage presents itself as an appealing alternative, particularly in hip and knee arthroplasty procedures. Intraoperative cell salvage involves the collection and reinfusion of a patient's own blood (autologous blood) lost during surgery. Studies have consistently shown that autologous blood collected via intraoperative cell salvage has fewer complications and greater benefits compared to donated blood. However, despite these advantages, the widespread adoption of intraoperative cell salvage in UK hospitals remains limited, primarily due to associated costs. While the integration of intraoperative cell salvage into blood management services may incur initial expenses, research suggests that it could ultimately prove to be cost-effective. This is because improved patient outcomes associated with intraoperative cell salvage may lead to reduced postoperative complications and shorter hospital stays. Thus, there is a growing imperative to overcome financial barriers and promote the implementation of intraopertive cell salvage as a standard practice in perioperative care across UK health care settings. The purpose of this scoping literature review is to consolidate the available information on the current use of intraoperative cell salvage and to identify intraoperative cell salvage techniques and devices described for use in an arthroplasty setting.

Abstract 4114994: Nursing Management Practice Variations related to Externalized Ventricular and Lumbar Drains

Introduction/Background: Nursing management of neurologic patients may include placement of externalized ventricular drains (EVDs) or lumbar drains (LDs) to monitor/drain cerebrospinal fluid (CSF), but knowledge and practice related to EVD management varies widely, despite a high potential for life-threatening complications. Limited data exists relative to the relationship between intracranial pressure (ICP) and CSF drainage. These gaps may undermine patient safety. Research Question: What are the nursing practices and perspectives regarding management of EVDs and LDs? Methods/Approach: A 16-question multiple-choice/text entry survey was distributed electronically to nurses and advanced practice nurses who were members of the American Association of Neuroscience Nurses. Data analysis included chi-square test for multiple choice responses, and qualitative data was analyzed using a six-step thematic analysis and an inductive approach. Results/Data: Of 219 participants, 42.8% reported roles as Neuroscience ICU nurses, and 39.2% managed an EVD at least 75% of the time. Neuro ICU nurses were most likely to have a patient with an EVD ( p =.002). Approximately 63% of respondents reported consulting with colleagues about EVDs nearly every time they cared for a patient with an EVD. Nurses reported a very high care burden, including re-leveling the transducer 4 or more times per shift (n=76), and re-zeroing every 8 hours (n=72) to assure accurate calibration. Of these 82.2% reported that they re-zeroed the EVD more often to obtain an accurate reading. Approximately 25% reported accidental over-drainage, some with negative outcomes. Many (79.3%) reported caring for patients with LDs, 47.4% to diagnose normal pressure hydrocephalus. The nursing care workload was described as 30-120 minutes each shift. Conclusion: A wide heterogeneity of nursing practices was revealed in EVD and LD management. No standardized nursing care practices have been adopted by nurses for the management of CSF. The complications of these practice variations have been shown to result in untoward patient outcomes. Increased patient morbidity and mortality are linked to catheter infection and over/under drainage of CSF and may be directly related nursing practice. This reveals critical need for improved, standardized care nursing practices in the management of EVDs and LDs, and an empiric understanding of the relationship between intracranial pressure and the volume and rate of CSF drainage.

Abstract 4136812: Optimal Pacing for Cerebral Perfusion: Elucidating Relationship Between Resting Pacemaker Heart Rate and Pulse Pressure

Background: Cognitive decline and dementia are significant global health concerns, with hypertension being a major risk factor. Increasingly, the elderly population is receiving pacemakers, and the pacing rates are set as low as 50bpm. Moreover, the relationship between blood pressure (BP) components, particularly diastolic BP (DBP) and pulse pressure (PP), and the risk of cognitive decline or dementia remains complex. The highest risk is observed in patients with low DBP and concurrently increased PP, likely indicating vascular stiffness. To our knowledge, no studies have assessed the programming of pacemakers to increase heart rates to target DBP and PP improving cerebral perfusion. Objectives: In patients with permanent pacemakers, resting heart rate (HR) can be artificially increased, and its consequence on hemodynamics, including PP, can be easily measured. This study aims to investigate the impact of increasing resting HR on PP in patients with poor vascular compliance. Secondary outcomes include evaluating changes in DBP, SBP, and cardiac output, as well as assessing patient tolerance to higher-paced heart rates through recording subjective symptoms. Methods: The study will employ a prospective cross-sectional interventional design. Digital plethysmography will be utilized to measure hemodynamic parameters, including systolic blood pressure (SBP), DBP, PP, and cardiac output, at baseline resting-paced heart rates. Subsequently, the pacemaker resting heart rate will be incrementally increased to a final rate of 100 beats per minute (bpm), with measurements taken 2-5 minutes after each change. Results: Ten out of twenty patients were recruited, with a mean age of 75.3 years old. The median change in PP from baseline HR of 70 to 100 was -8.7% (IQR -18.8 - +2.8, p= 0.114), SBP 4.2% (IQR 0 – 11.9, p=0.059), and DBP 20.1% (IQR 12.9 -23, p=0.005). There were no adverse outcomes and no patient-reported symptoms during higher pacing rates. Conclusion: This study provides the basis for proof of concept. Since an increased HR decreases PP, this will be subsequently tested against improvement in cerebral perfusion by cerebral Doppler studies, and its impact on cognitive function will be tested. This has the potential to change the standard of practice for patients with pacemakers and allow for collaboration across multiple specialties such as neurology, geriatric medicine and cardiology.

Reducing ACL injury risk: A meta-analysis of prevention programme effectiveness.

The aim of this study was to conduct a meta-analysis of the literature regarding anterior cruciate ligament (ACL) injury prevention programmes (IPPs) in order to assess the effectiveness of ACL prevention programmes based on current high-quality studies. The hypothesis was that the implementation of ACL IPPs significantly reduces the incidence of ACL ruptures compared to standard practice. A meta-analysis of the literature was conducted using the databases PubMed, EMBASE, MEDLINE, CINHAL and Cochrane Central Register of Controlled Trials. The search terms utilized were ACL, injury, knee, control and prevention. The collected data and reported clinical outcomes were independently gathered by three different individuals. After evaluating the heterogeneity of the studies, the DerSimonian-Laird random effects models were employed to determine the pooled risk ratios (RRs) and the risk differences (RDs) regarding ACL Injuries. The RD was utilized to ascertain the number needed to treat. The search strategy identified 743 studies, of which 11 met all inclusion and quality criteria for pooled analysis. The total number of study participants was 16,316. The overall RR of sustaining an ACL injury in the intervention group was 0.36 (95% confidence interval [CI]: 0.23 to 0.57) of the control group, showing a significant reduction in the ACL injury risk of the intervention group (p < 0.001). We identified an RD of -1.4% (95% CI: -2.4% to -0.4%) in favour of the intervention group. The number needed to treat in preventing one ACL rupture was 71. In conclusion, the study clearly demonstrates a significant positive preventive effect of training programmes concerning ACL injuries (p < 0.001). The pooled estimates indicate that such programmes result in a significant reduction of ACL injury risks (p < 0.001). Despite the moderate quality of the included literature, the results exhibit robustness. However, based on the literature examined, no definitive superior training programme could be identified. II.

Protecting Emergency Responders with Evidence-Based Interventions (PEREI): protocol for a randomized controlled trial for early career emergency responders, significant others, and supervisors

ABSTRACT Background: Emergency service personnel perform roles associated with high levels of trauma exposure and stress, and not surprisingly experience greater risk for poor mental health including posttraumatic stress disorder (PTSD), depression, anxiety, and substance use relative to the general population. Although programs exist to minimise the risk of developing mental health problems, their efficacy to date has been limited or untested. We will test the efficacy of the three programs which form PEREI: Protecting Emergency Responders with Evidence-Based Interventions. PEREI consists of modified versions of internet-delivered cognitive training in resilience (iCT-R) for early career first responders, PEREI-S for supervisors, and Be Well for Significant Others (BW-SO). Method: Up to 450 members in their first 5 years of service across multiple agencies will be recruited, with their adult supports (significant others, friends) invited to participate. Up to 180 supervisors in the agencies will be recruited. Participants will be randomized to their respective program or to receive the standard practice for mental health offered by the service (or usual mental health support for significant others). Assessments will be conducted pre- and post-program, and at 6- and 12-month follow-up. Primary outcome is PTSD and depression severity and probable-diagnosis. Secondary measures will index hypothesized mediators and moderators of outcome and determine whether the programs are cost-effective. Conclusions: The results will provide evidence as to efficacious methods for reducing risk of mental health problems in high-risk occupations, a better understanding of how such interventions may work, and whether they are good value for money. Trial registration: www.anzctr.org.au (ACTRN12622001267741)