The association between iron deficiency and outcomes: a secondary analysis of the intravenous iron therapy to treat iron deficiency anaemia in patients undergoing major abdominal surgery (PREVENTT) trial

In the intravenous iron therapy to treat iron deficiency anaemia in patients undergoing major abdominal surgery (PREVENTT) trial, the use of intravenous iron did not reduce the need for blood transfusion or reduce patient complications or length of hospital stay. As part of the trial protocol, serum was collected at randomisation and on the day of surgery. These samples were analysed in a central laboratory for markers of iron deficiency. We performed a secondary analysis to explore the potential interactions between pre-operative markers of iron deficiency and intervention status on the trial outcome measures. Absolute iron deficiency was defined as ferritin <30 μg.l^-1 ; functional iron deficiency as ferritin 30-100 μg.l^-1 or transferrin saturation < 20%; and the remainder as non-iron deficient. Interactions were estimated using generalised linear models that included different subgroup indicators of baseline iron status. Co-primary endpoints were blood transfusion or death and number of blood transfusions, from randomisation to 30 days postoperatively. Secondary endpoints included peri-operative change in haemoglobin, postoperative complications and length of hospital stay. Most patients had iron deficiency (369/452 [82%]) at randomisation; one-third had absolute iron deficiency (144/452 [32%]) and half had functional iron deficiency (225/452 [50%]). The change in pre-operative haemoglobin with intravenous iron compared with placebo was greatest in patients with absolute iron deficiency, mean difference 8.9 g.l^-1 , 95%CI 5.3-12.5; moderate in functional iron deficiency, mean difference 2.8 g.l^-1 , 95%CI -0.1 to 5.7; and with little change seen in those patients who were non-iron deficient. Subgroup analyses did not suggest that intravenous iron compared with placebo reduced the likelihood of death or blood transfusion at 30 days differentially across subgroups according to baseline ferritin (p = 0.33 for interaction), transferrin saturation (p = 0.13) or in combination (p = 0.45), or for the number of blood transfusions (p = 0.06, 0.29, and 0.39, respectively). There was no beneficial effect of the use of intravenous iron compared with placebo, regardless of the metrics to diagnose iron deficiency, on postoperative complications or length of hospital stay.

Intraarticular steroids as DMARD-sparing agents for juvenile idiopathic arthritis flares: Analysis of the Childhood Arthritis and Rheumatology Research Alliance Registry

BACKGROUND

Children with juvenile idiopathic arthritis (JIA) who achieve a drug free remission often experience a flare of their disease requiring either intraarticular steroids (IAS) or systemic treatment with disease modifying anti-rheumatic drugs (DMARDs). IAS offer an opportunity to recapture disease control and avoid exposure to side effects from systemic immunosuppression. We examined a cohort of patients treated with IAS after drug free remission and report the probability of restarting systemic treatment within 12 months.

METHODS

We analyzed a cohort of patients from the Childhood Arthritis and Rheumatology Research Alliance (CARRA) Registry who received IAS for a flare after a period of drug free remission. Historical factors and clinical characteristics and of the patients including data obtained at the time of treatment were analyzed.

RESULTS

We identified 46 patients who met the inclusion criteria. Of those with follow up data available 49% had restarted systemic treatment 6 months after IAS injection and 70% had restarted systemic treatment at 12 months. The proportion of patients with prior use of a biologic DMARD was the only factor that differed between patients who restarted systemic treatment those who did not, both at 6 months (79% vs 35%, p < 0.01) and 12 months (81% vs 33%, p < 0.05).

CONCLUSION

While IAS are an option for all patients who flare after drug free remission, it may not prevent the need to restart systemic treatment. Prior use of a biologic DMARD may predict lack of success for IAS. Those who previously received methotrexate only, on the other hand, are excellent candidates for IAS.

Inequalities in accessing quality healthcare, does insurance play a role? retrospective analysis of aortic emergencies from national inpatient sample 2019

Background

Aortic emergencies, dissection and rupture, are rare but catastrophic entities, with the cornerstone to survival being prompt diagnosis and treatment. Insurance status often limits access to healthcare, and our study aims to determine if it plays a role in the outcomes of aortic emergencies.

Method

A retrospective analysis of the 2019 Nationwide Inpatient Sample was conducted to identify hospitalization (Age ≥18 & non-elective) with aortic dissection and ruptured aortic aneurysms using ICD-10 codes. Discharge-level weight analysis was used to produce a national estimate. Variables were screened with univariate regression, and intermediate and co-linear variables were screened-out before a multivariable regression analysis model was built and performed to calculate the odds ratio.

Results

A total of 19,685 (0.06%) hospitalizations are identified for aortic emergencies (14965 dissections & 4720 ruptured aneurysms). The mean age was 58.56, 62.7% were males, and ethnic distribution was 65.1% white, 19.5% blacks, 7.6% Hispanics, and others.

11.4% of the hospitalizations underwent diagnostic imaging with either CTA/MRA/TEE/Aortography within 24 hours. Hypotension/shock was present in 32% of these hospitalizations and was a risk factor for mortality OR 3.21 (p&lt;0.00), increasing LOS by an average of 5.1 days and resource utilization by 156,000$. Another risk factor for mortality was stroke/TIA (OR-1.76, p&lt;0.00), increasing LOS and resource utilization by 3.1 days and 80,662$, respectively.

3220 hospitalizations (16.4%) did not survive the course, and the mortality rate in uninsured, Medicare, and Medicaid was 17%, 20%,9% compared with 12% in privately insured. On crude analysis, uninsured and medicare patients appeared to have higher odds of mortality [OR 1.50, p&lt;0.04, and OR 1.83 p-value &lt;0.002 respectively], however upon adjusting for confounders, only uninsured patients showed statistically significant difference (OR 2.13, p&lt;0.002). Similar results were corroborated on analyzing hospitalizations for aortic dissection; however, insurance status did not influence mortality in a ruptured aneurysm.

When comparing hospitalization of median household income of ≥79,000$ with household of median income of 59,000–78,999 $, 46,000–58,999 $ and &lt;46,000$ had higher odds of mortality (OR-1.38, p&lt;0.04), (OR-1.44, p&lt;0.02) and (OR-1.44, p&lt;0.03) respectively. Of all the insurance types, a statistically significant difference compared with private insurance, Medicaid on average, had 2.8 more days and incurred an additional 62,912$ in resource utilization (p&lt;0.00).

Conclusion

Inequalities in accessing healthcare, median household income, and insurance status are risk factors for mortality in aortic emergencies. Efforts are needed to bridge the gap in this particular facet of social determinants of health to find a sustainable and equitable solution for quality healthcare for aall regardless of their insurance status.

Funding Acknowledgement

Type of funding sources: None.

Social determinants of health influence disease activity and functional disability in Polyarticular Juvenile Idiopathic Arthritis

BACKGROUND

Social determinants of health (SDH) greatly influence outcomes during the first year of treatment in rheumatoid arthritis, a disease similar to polyarticular juvenile idiopathic arthritis (pJIA). We investigated the correlation of community poverty level and other SDH with the persistence of moderate to severe disease activity and functional disability over the first year of treatment in pJIA patients enrolled in the Childhood Arthritis and Rheumatology Research Alliance Registry.

METHODS

In this cohort study, unadjusted and adjusted generalized linear mixed effects models analyzed the effect of community poverty and other SDH on disease activity, using the clinical Juvenile Arthritis Disease Activity Score-10, and disability, using the Child Health Assessment Questionnaire, measured at baseline, 6, and 12 months.

RESULTS

One thousand six hundred eighty-four patients were identified. High community poverty (≥20% living below the federal poverty level) was associated with increased odds of functional disability (OR 1.82, 95% CI 1.28-2.60) but was not statistically significant after adjustment (aOR 1.23, 95% CI 0.81-1.86) and was not associated with increased disease activity. Non-white race/ethnicity was associated with higher disease activity (aOR 2.48, 95% CI: 1.41-4.36). Lower self-reported household income was associated with higher disease activity and persistent functional disability. Public insurance (aOR 1.56, 95% CI 1.06-2.29) and low family education (aOR 1.89, 95% CI 1.14-3.12) was associated with persistent functional disability.

CONCLUSION

High community poverty level was associated with persistent functional disability in unadjusted analysis but not with persistent moderate to high disease activity. Race/ethnicity and other SDH were associated with persistent disease activity and functional disability.

130 Paediatric Hand Fractures Requiring Surgery – the Results of a Bespoke Hand Surgery Service

Aim

To evaluate the management of The Royal Devon and Exeter Hospital (RD&E) bespoke hand surgery service on paediatric closed hand fractures. In particular, an assessment against The British Society for Surgery of the Hand (BSSH) closed fracture standards on treatment timelines and national guidance compliance.

Method

A retrospective review of all paediatric patients requiring plastic surgery seen at the RD&E plastics trauma clinic from 1st Nov 2020 to 28th Feb 2021 was performed. This was compared to two previous audit cycles completed during winter 2019 and summer 2020. Health informatics was collated via our IT department and thoroughly reviewed using departmental notes. Exclusion criteria included: all non-fracture injuries, patients &gt; 18 years old and open fractures.

Results

In winter 2020–21 all patients were referred the same day of injury and 92% were seen by a Plastic Surgeon within 24 hours of injury. This was an improvement from the mean time from referral to clinic of 5 days in winter 2019 and 1.33 days in summer 2020 respectively. 85% of cases are now operated within 48 hours of review and 92% of cases were operated within 72 hours of the decision to operate where conservative management had failed.

Conclusions

The introduction of a ‘rapid-access’ musculoskeletal unit with early senior review and a dedicated theatre has created ‘gold-standard’ compliance with national standards for the operative management of closed paediatric fractures. We should continue to focus on improving and increasing capacity of this service as it has likely improved both the patient journey and outcomes.

1018 Did COVID Compromise the Care of Closed Paediatric Hand Fractures?

Aim

To assess the effect of a ‘rapid-access’ musculoskeletal unit, established in March 2020, as part of the Royal Devon & Exeter hospital COVID response, with direct assessment of hand trauma by the Plastic Surgery department staff, on treatment timelines and national guidance compliance for closed paediatric hand fractures.

Method

This was a retrospective review from 1st January to 31st December 2019 and a prospective study from the 1st April to 15th June 2020. The retrospective cases were collated by health informatics. The prospective data was recorded on the department’s database. Exclusion criteria: nail bed injuries with tuft fractures, ligament injuries only, open fractures and patients aged 18 at time of surgery.

Results

In 2019 the majority (73%) of patients (n = 26) were referred within 48hrs but waited a median of 5 days to be seen in clinic by a hand surgeon resulting in significant delays in treatment. After service reconfiguration in 2020, all patients (n = 6) were operated on within 72 hours of the decision to operate - mean time to surgery 1.5 days (range 0-3 days). The mean time from referral to clinic was 1.33 days (range 0-6 days). 4 patients were operated on within 7 days of injury. Of the 2 patients operated on &gt; 7 days, 1 was referred 32 days post injury and 1 failed conservative management.

Conclusions

The introduction of a ‘rapid-access’ musculoskeletal unit with early senior review and a dedicated theatre has created ‘gold-standard’ compliance with national standards for the operative management of closed paediatric fractures.

89 Do Corticosteroid and Local Anaesthetic Hip Injections Administered Proximal or Distal to The Zona Orbicularis Have an Effect on Patient Satisfaction?

Aim

Pubofemoral and ischiofemoral ligaments blend to make zona orbicularis. Zonaorbicularis has been suggested to force fluid from peripheral compartment to central compartment in unidirectional flow. This study aims to assess whether injection of corticosteroid with local anaesthetic injected either proximal or distal to the zona orbicularis has effect on patient satisfaction.

Method

This retrospective study investigated consecutive patients undergoing ultrasound guided hip injections at a single centre in the UK between November 2018 and March 2019. Patients were identified using IMPAX© picture archiving and communications system. Radiographs were assessed to see if radiopaque dye and therefore corticosteroid and local anaesthetic had been injected proximal or distal to the zona orbicularis. Clinic letters were accessed on the electronic patient record and we recorded whether patients had pain relief at 24 hours and 2 weeks following hip injection.

Results

133 Patients were identified during the study period, of which 40 were included. At 24 hours post-injection 72% of patients were satisfied and 28% were unsatisfied, for which there was 76% and 70% satisfaction for proximal and distal injections respectively (p = 0.63). At 2 weeks post-injection 45% of patients were satisfied and 55% of patients unsatisfied, for which there was 47% and 44% satisfaction for proximal and distal injections respectively (p = 0.9).

Conclusions

Overall patient satisfaction is high following hip corticosteroid and local anaesthetic injection. No difference was found between injections proximal and distal to the zona orbicularis. Further research is needed to quantify the association between proximal and distal injections.

Wildland Fire Emission Sampling at Fishlake National Forest, Utah Using an Unmanned Aircraft System

Emissions from a stand replacement prescribed burn were sampled using an unmanned aircraft system (UAS, or "drone") in Fishlake National Forest, Utah, U.S.A. Sixteen flights over three days in June 2019 provided emission factors for a broad range of compounds including carbon monoxide (CO), carbon dioxide (CO₂), nitric oxide (NO), nitrogen oxide (NO₂), particulate matter < 2.5 microns in diameter (PM_2.5), volatile organic compounds (VOCs) including carbonyls, black carbon, and elemental/organic carbon. To our knowledge, this is the first UAS-based emission sampling for a fire of this magnitude, including both slash pile and crown fires resulting in wildfire-like conditions. The burns consisted of drip torch ignitions as well as ground-mobile and aerial helicopter ignitions of large stands comprising over 1,000 ha, allowing for comparison of same-species emission factors burned under different conditions. The use of a UAS for emission sampling minimizes risk to personnel and equipment, allowing flexibility in sampling location and ensuring capture of representative, fresh smoke constituents. PM_2.5 emission factors varied 5-fold and, like most pollutants, varied inversely with combustion efficiency resulting in lower emission factors from the slash piles than the crown fires.

Second round results from the Manchester 'Lung Health Check' community-based targeted lung cancer screening pilot

We report results from the second annual screening round (T1) of Manchester's 'Lung Health Check' pilot of community-based lung cancer screening in deprived areas (undertaken June to August 2017). Screening adherence was 90% (n=1194/1323): 92% of CT scans were classified negative, 6% indeterminate and 2.5% positive; there were no interval cancers. Lung cancer incidence was 1.6% (n=19), 79% stage I, treatments included surgery (42%, n=9), stereotactic ablative radiotherapy (26%, n=5) and radical radiotherapy (5%, n=1). False-positive rate was 34.5% (n=10/29), representing 0.8% of T1 participants (n=10/1194). Targeted community-based lung cancer screening promotes high screening adherence and detects high rates of early stage lung cancer.

Implementing lung cancer screening: baseline results from a community-based 'Lung Health Check' pilot in deprived areas of Manchester

We report baseline results of a community-based, targeted, low-dose CT (LDCT) lung cancer screening pilot in deprived areas of Manchester. Ever smokers, aged 55-74 years, were invited to 'lung health checks' (LHCs) next to local shopping centres, with immediate access to LDCT for those at high risk (6-year risk ≥1.51%, PLCOM2012 calculator). 75% of attendees (n=1893/2541) were ranked in the lowest deprivation quintile; 56% were high risk and of 1384 individuals screened, 3% (95% CI 2.3% to 4.1%) had lung cancer (80% early stage) of whom 65% had surgical resection. Taking lung cancer screening into communities, with an LHC approach, is effective and engages populations in deprived areas.

Closure of the perineal defect after abdominoperineal excision for rectal adenocarcinoma - ACPGBI Position Statement

BACKGROUND

Perineal wound morbidity is common following abdominoperineal excision of the rectum (APE). There is no consensus on the optimum perineal reconstruction method after APE, and in particular 'extra-levator APE' (ELAPE).

METHODS

A systematic review of the PubMed, Embase and Cochrane databases was performed. This position statement formulated clinical questions and graded the evidence to make recommendations.

RESULTS

Perineal wound complications may be higher following ELAPE compared to 'conventional APE (cAPE)' however there is insufficient evidence to recommend cAPE over ELAPE with regards to the impact upon perineal wound healing. The majority of cAPE studies have used primary closure with varying complication rates reported. Where concerns regarding perineal wound healing exist, myocutaneous flap closure may be considered as an alternative method. There is minimal available evidence on perineal mesh reconstruction following cAPE. Primary closure, mesh use and myocutaneous flap reconstruction following ELAPE has been reported although variations in definitions and low-quality of available evidence limit comparison. There is insufficient evidence to recommend one particular method of perineal closure after ELAPE. Primary perineal closure is likely to have a higher risk of perineal herniation. Myocutaneous flaps and biological mesh have been effectively used in ELAPE closure. There is insufficient evidence to support one particular type of flap or mesh. Perineal wound complication rates are significantly increased when neo-adjuvant radiotherapy is delivered, regardless of surgical technique. There is no evidence that laparoscopy reduces APE perineal wound complications.

CONCLUSION

This position statement updates clinicians on current evidence around perineal closure after APE surgery.

Effect of sodium molybdate supplementation on high concentrations of Cu in liver of yearling bulls

AIM

To determine the impact of sodium molybdate treatment, given weekly, on concentrations of Cu in liver, activity of liver enzymes, and weight gain over 4 weeks, in yearling bulls with elevated concentrations of Cu in liver.

METHODS

The study was carried on two commercial grazing farms in the Otago region of New Zealand in yearling Friesian bulls (n=150 on Farm A and n=49 on Farm B) with mean concentration of Cu in liver >3,000 µmol/kg fresh weight. On Day 0, all animals were weighed and half were systematically allocated to treatment with sodium molybdate (3 mg/kg liveweight on Farm A and 7 mg/kg liveweight on Farm B); the remainder received no treatment (Control). Sodium molybdate was given as a drench weekly for 4 weeks and all animals were weighed again on Day 28. Ten animals on each farm (five from each treatment group) were systematically selected for blood sampling and liver biopsies on Days 0 and 28. Samples were analysed for concentrations of Cu in plasma, vitamin B₁₂ in serum, activities of γ-glutamyl transferase, aspartate aminotransferase and glutamate dehydrogenase in serum, and concentrations of Cu and vitamin B₁₂ in liver. Separate multivariable linear models were used to compare the change in outcome variables between Days 0 and 28 between bulls that had been drenched with sodium molybdate or not.

RESULTS

On Farm A, mean concentrations of Cu in liver on Day 28, as a percentage of concentrations on Day 0, for the control group was 55 (95% CI=40-73)% and for the treatment group was 73 (95% CI=43-111)%. On Farm B, the equivalent mean for the control group was 75 (95% CI=42-131)% and for the treatment group was 85 (95% CI=38-134)%. The multivariable linear models indicated that the changes in concentrations of Cu in liver, activities of liver enzymes and weight gain between Days 0 and 28 did not differ between the bulls treated or not with sodium molybdate (p>0.18).

CONCLUSIONS AND CLINICAL RELEVANCE

Treatment with sodium molybdate in one bolus at weekly intervals for 4 weeks did not affect concentrations of Cu in liver, activity of liver enzymes or weight gain in animals with high concentrations of Cu liver on two farms.

Evidence-based management of adult trigger digits

The aim of this systematic review was to develop an evidence-based guideline to assist clinicians in the treatment of adult trigger digits. There is moderate evidence to suggest that local corticosteroid injection is a safe and effective short-term treatment and it may, therefore, be recommended as an initial treatment for this condition. However, when compared with surgery, there is strong evidence that corticosteroid injection is associated with increased rates of ongoing or recurrent symptoms at 6 months after intervention. There is strong evidence suggesting that trigger digit can be managed safely by surgical release. There is weak evidence to support the use of splinting or other non-operative modalities. Hence a single corticosteroid injection may be offered as the first line in treatment of adult trigger digits, but percutaneous release is a safe alternative. Surgery should be the next line if the injection fails, symptoms recur or the patient chooses.

LEVEL OF EVIDENCE

I.

Patients with myeloma need more time to ask questions

According to a report by charity Myeloma UK, many patients are unsure about the issues they should be discussing with their nurse and other healthcare professionals.