Surgical Management of Synucleinopathies

Synucleinopathies represent a diverse set of pathologies with significant morbidity and mortality. In this review, we highlight the surgical management of three synucleinopathies: Parkinson’s disease (PD), dementia with Lewy bodies (DLB), and multiple system atrophy (MSA). After examining underlying molecular mechanisms and the medical management of these diseases, we explore the role of deep brain stimulation (DBS) in the treatment of synuclein pathophysiology. Further, we examine the utility of focused ultrasound (FUS) in the treatment of synucleinopathies such as PD, including its role in blood–brain barrier (BBB) opening for the delivery of novel drug therapeutics and gene therapy vectors. We also discuss other recent advances in the surgical management of MSA and DLB. Together, we give a diverse overview of current techniques in the neurosurgical management of these pathologies.

National audit of non-melanoma skin cancer excisions performed by plastic surgery in the UK

A national, multi-centre audit of non-melanoma skin cancer excisions by plastic surgery.

Virtual Reality Hemifield Measurements for Corrective Surgery Eligibility in Ptosis Patients: A Pilot Clinical Trial

Purpose

We developed an accelerated virtual reality (VR) suprathreshold hemifield perimetry algorithm, the median cut hemifield test (MCHT). This study examines the ability of the MCHT to determine ptosis severity and its reversibility with an artificial improvement by eyelid taping on an HTC Vive Pro Eye VR headset and the Humphrey visual field analyzer (HVFA) to assess the capabilities of emerging technologies in evaluating ptosis.

Methods

In a single visit, the MCHT was administered along with the HVFA 30-2 on ptotic untaped and taped eyelids in a randomized order. The primary end points were a superior field visibility comparison with severity of VF loss and VF improvement after taping for MCHT and HVFA. Secondary end points included evaluating patients' Likert-scaled survey responses on the comfort, speed, and overall experience with both testing modalities.

Results

VR's MCHT superior field degrees visible correlated well for severe category margin to reflex distance (r = 0.78) compared with HVFA's (r = -0.21). The MCHT also demonstrated noninferiority (83.3% agreement; P = 1) against HVFA for detection of 30% or more superior visual field improvement after taping, warranting a corrective surgical intervention. In comparing hemi-VF in untaped eyes, both tests demonstrated relative obstruction to the field when comparing normal controls to severe ptosis (HVFA P < 0.05; MCHT P < 0.001), which proved sufficient to demonstrate percent improvement with taping. The secondary end point of patient satisfaction favored VR vision testing presentation mode in terms of comfort (P < 0.01), speed (P < 0.001), and overall experience (P < 0.01).

Conclusions

This pilot trial supports the use of MCHT for the quantitative measurement of visual field loss owing to ptosis and the reversibility of ptosis that is tested when conducting a presurgical evaluation. We believe the adoption of MCHT testing in oculoplastic clinics could decrease patient burden and accelerate time to corrective treatment.

Translational Relevance

In this study, we look at vision field outputs in patients with ptosis to evaluate its severity and improvement with eyelid taping on a low-profile VR-based technology and compare it with HVFA. Our results demonstrate that alternative, portable technologies such as VR can be used to grade the degree of ptosis and determine whether ptosis surgery could provide a significant superior visual field improvement of 30% or more, all while ensuring a more comfortable experience and faster testing time.

The learning curve and safety of continuous intraoperative vagus nerve monitoring in thyroid surgery

INTRODUCTION

Continuous intraoperative nerve monitoring allows for continuous feedback on the integrity of the recurrent laryngeal nerve (RLN) and the quality of its induced myogenic potential. The aims of this study were to assess the time requirements and risks associated with vagus nerve electrode placement when learning the technique.

METHODS

This is a prospective observational study carried out in a single otolaryngology department at the start of a trainee's placement. A total of 40 vagus nerve dissections in 31 consecutive operations (22 hemithyroidectomies, 9 total thyroidectomies) using automatic periodic stimulation (APS, Medtronic) are included. Of the electrode placements, 10 were performed by the trainer and 30 by the trainee. The time required for each surgical step and complications relating to vagus nerve dissection were recorded.

RESULTS

The average (median+IQR) total additional time attributable to vagus nerve dissection, electrode placement and baseline electromyogenic assessment was 3.1mins (2.5-3.3) for the trainer and 4.8mins (4.1-5.3) for the trainee (p<0.0001). There was a downward trend in time requirement for the trainee (not statistically significant, p=0.080). Total operative time was 38min (35-45) for hemithyroidectomy and 56min (53-62) for total thyroidectomy. There was a mix of benign (74%) and malignant (26%) histology, no intraoperative complications relating to autonomic dysfunction and one (2.5%) transient nerve palsy.

CONCLUSIONS

Operative time attributable to vagus nerve electrode placement is short and the procedure is easy to learn. Appropriate surgical technique and careful anaesthetic considerations allow monitoring to be performed safely, and may reduce the rate of RLN palsy.

Fusion product measurements by nuclear diagnostics in the Joint European Torus deuterium-tritium 2 campaign (invited)

A new deuterium-tritium experimental, DTE2, campaign has been conducted at the Joint European Torus (JET) between August 2021 and late December 2021. Motivated by significant enhancements in the past decade at JET, such as the ITER-like wall and enhanced auxiliary heating power, the campaign achieved a new fusion energy world record and performed a broad range of fundamental experiments to inform ITER physics scenarios and operations. New capabilities in the area of fusion product measurements by nuclear diagnostics were available as a result of a decade long enhancement program. These have been tested for the first time in DTE2 and a concise overview is provided here. Confined alpha particle measurements by gamma-ray spectroscopy were successfully demonstrated, albeit with limitations at neutron rates higher than some 10¹⁷ n/s. High resolution neutron spectroscopy measurements with the magnetic proton recoil instrument were complemented by novel data from a set of synthetic diamond detectors, which enabled studies of the supra-thermal contributions to the neutron emission. In the area of escaping fast ion diagnostics, a lost fast ion detector and a set of Faraday cups made it possible to determine information on the velocity space and poloidal distribution of the lost alpha particles for the first time. This extensive set of data provides unique information for fundamental physics studies and validation of the numerical models, which are key to inform the physics and scenarios of ITER.

571 Evaluating the Effectiveness of Extracorporeal Shockwave Lithotripsy (ESWL) for Ureteric Stones During COVID-19 Pandemic - A Single Centre Experience

Aim

Reliance on ESWL for treating ureteric stone has increased during the COVID-19 pandemic. We examined the outcomes for ureteric stones treated with our on-site lithotripter to assess the success rate and determine the variables that could affect the outcome results.

Method

A retrospective review using electronic records and images of patients who underwent ESWL for ureteric stones (January to December 2020). Univariate and multivariate analysis used to determine stone-free rate predictors (Stone Free rate/SFR: No residual stones on post-ESWL imagining).

Results

A total of 36 patients underwent ESWL for ureteric stones. Mean age was 58 years (21–90), and mean stone size was 8 mm (5–20). Stones were located in the proximal (67%) or lower ureter (33%). Overall SFR was 64% (67% proximal, 33% distal). 64% of patients required only one session to be stone free, with 60% stone free after two sessions. Stones <10mm had a SFR of 67%, compared to 58% for stone >10 mm. The only statistically significant predictor was stone size (longest dimension, p=0.04). No statistical significance with stone location (P=0.09), skin-to-stone distance (SSD) (P=0.7), stone density (P=0.3) or stone volume (P=0.3). In treatment failure, time to definitive ureteroscopy was 4 weeks.

Conclusion

Our overall SFR was slightly lower than expected but comparable to available literature. This data highlights the importance of patient selection for ESWL and would be useful in counselling about local success rate. More than half of the patients required only one session for stone clearance and stone size was the only significant predictor for successful ESWL.

The influence of site on the incidence and diagnosis of solitary central cartilage tumours of the femur. A 21st century perspective

OBJECTIVE

To determine the incidence of central cartilage tumours (CCTs) in the femur and the impact of site (proximal, mid and distal thirds) on tumour grade. To compare study results with historically published data.

MATERIALS AND METHODS

Retrospective review of solitary CCTs arising in the femur over the past 13 years. Data collected included location (proximal, mid and distal thirds) and final diagnosis in terms of tumour grade based on imaging features ± histology. Case material collected from three bone tumour textbooks provided historical data.

RESULTS

430 solitary CCTs were included in the femur. 73% cases arose in the distal, 3.7% in the mid and 23% in the proximal femur. The ratio of "benign" (combining enchondroma and atypical cartilaginous tumour (ACT)) to higher grade chondrosarcoma (CS) was 11:1 in the distal, 1:1 in the mid and 1:1.5 in the proximal femur, the distribution of benign to malignant tumours being significantly different between the regions (F test, p < 0.05). Comparison with historical data showed a reversal of the benign (enchondroma) to malignant (ACT and higher grade CS) of 30%:70%-84%:16% in the current series.

CONCLUSIONS

The site of origin of a CCT in the femur has an impact on final diagnosis with CS uncommon in the distal as compared with the mid and proximal femur. This is in contradistinction to historical data where the incidence of CS exceeded that of enchondroma at all sites.

O003 Radiation-related chromosomal aberrations observed in high volume endovascular operators performing X-ray guided surgery

Introduction

The biological effects of chronic, low dose radiation, to which operators performing fluoroscopy-guided procedures are exposed, are unknown. We have previously demonstrated acute DNA damage/repair in lymphocytes from operators performing fluoroscopy-guided endovascular aneurysm repair (EVAR), but these markers normalised after 24 hours and did not inform on the residual accumulated effects of chronic radiation exposure. In the present study cytogenetic techniques were used to examine for chromosomal aberrations in endovascular operators.

Methods

Peripheral blood lymphocytes were isolated from high volume endovascular operators performing EVAR and age-matched radiation naïve general surgeons as controls. Giemsa staining was used to visualise the full complement of chromosomes and all dicentrics, where 2 centromeres are present in a single chromosome, were identified. The genome was analysed for abnormal exchanges of genetic material between chromosomes using multiplex fluorescence in situ hybridisation (mFISH).

Results

Lymphocytes from 18 operators (12 exposed, 6 controls) were analysed. A higher frequency of dicentric chromosomes were found in exposed operators compared with controls (0.0011 vs 0.0004, respectively, P=0.002) after examining 54,000 lymphocytes. Twice as many complex chromosome rearrangements were seen in endovascular operators compared with controls (0.48% vs 0.24%). Aneuploidy, the abnormal loss of chromosomes, was more frequent in endovascular operators with a median difference of 0.35 per chromosome (P=0.004).

Conclusion

We have found a higher frequency of chromosomal aberrations in endovascular operators compared with radiation naïve colleagues. This justifies further individual biological profiling for genomic instability and personalised radiation risk assessment.

Take-home message

Radiation-related DNA damage occurs in endovascular operators despite current radiation protection measures. Biological dosimetry could be a useful tool, allowing personalised risk assessment.

O099 Position and number of anchors in hip arthroscopy labrum repair: a systematic review

Introduction

Hip labral tears are reported in 22–55% of patients with hip or groin pain. Operative treatment is necessary for most cases, via hip arthroscopy with the use of suture anchors. This systematic review aims to determine the optimal number and position of anchors in hip labral repair.

Methods

Pubmed, Ovid & Embase were searched, and 2 researchers independently screened the 1,304 results. Outcome measures such as procedures performed, number & (clockface) position of anchors, failure & articular involvement of anchors were extracted.

Results

5 studies were included in the analysis: 1 Cross-Sectional Study (1645 Hips, mean age (MA):33.7 years), 3 Retrospective case studies (491 hips, MA:31.0) and 1 Controlled Cadaveric study (32 cadaveric hips, MA:62.7). Chi-squared statistical analysis of 323 hips found a significant difference (X2 (2, N = 323) = 17.88, p &lt; .001) in the risk of articular involvement with the position of anchors at 11°-12° o’clock, 1°-2° and 3°-4°. There is an absolute risk reduction (ARR) of 19% with anchors positioned at 11°-12° compared to anchors positioned at 3°-4° (X2 (1, N=178) =15.79, p &lt; .001) and an ARR of 12% with anchors at 1°-2° compared to anchors positioned at 3°-4° (X2 (1, N = 237) = 15.79, p &lt; .0109). Additionally, by assessing 1645 operations it was found that for tears spanning &gt;2 hours, a minimum of 2 anchors was placed.

Conclusion

Placement of anchors in the 3°-4° o’clock position carries the highest risk for articular involvement. Small diameter anchors and careful placement can be used to minimize articular injury. Preferable positions of anchors are 11°-12°, furthermore, for tears spanning over 2 hours, a minimum of 2 anchors was placed.

Take-home message

In Hip Arthroscopy labral repair, placement of anchors in the 3°-4° o’clock position carries the highest risk for articular involvement. Small diameter anchors and 2 hours. flexible anchor instrumentation can be used to minimize articular injury, furthermore, for tears spanning over 2 hours, a minimum of 2 anchors was placed.

Evaluation of prognostic risk models for postoperative pulmonary complications in adult patients undergoing major abdominal surgery: a systematic review and international external validation cohort study

BACKGROUND

Stratifying risk of postoperative pulmonary complications after major abdominal surgery allows clinicians to modify risk through targeted interventions and enhanced monitoring. In this study, we aimed to identify and validate prognostic models against a new consensus definition of postoperative pulmonary complications.

METHODS

We did a systematic review and international external validation cohort study. The systematic review was done in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. We searched MEDLINE and Embase on March 1, 2020, for articles published in English that reported on risk prediction models for postoperative pulmonary complications following abdominal surgery. External validation of existing models was done within a prospective international cohort study of adult patients (≥18 years) undergoing major abdominal surgery. Data were collected between Jan 1, 2019, and April 30, 2019, in the UK, Ireland, and Australia. Discriminative ability and prognostic accuracy summary statistics were compared between models for the 30-day postoperative pulmonary complication rate as defined by the Standardised Endpoints in Perioperative Medicine Core Outcome Measures in Perioperative and Anaesthetic Care (StEP-COMPAC). Model performance was compared using the area under the receiver operating characteristic curve (AUROCC).

FINDINGS

In total, we identified 2903 records from our literature search; of which, 2514 (86·6%) unique records were screened, 121 (4·8%) of 2514 full texts were assessed for eligibility, and 29 unique prognostic models were identified. Nine (31·0%) of 29 models had score development reported only, 19 (65·5%) had undergone internal validation, and only four (13·8%) had been externally validated. Data to validate six eligible models were collected in the international external validation cohort study. Data from 11 591 patients were available, with an overall postoperative pulmonary complication rate of 7·8% (n=903). None of the six models showed good discrimination (defined as AUROCC ≥0·70) for identifying postoperative pulmonary complications, with the Assess Respiratory Risk in Surgical Patients in Catalonia score showing the best discrimination (AUROCC 0·700 [95% CI 0·683-0·717]).

INTERPRETATION

In the pre-COVID-19 pandemic data, variability in the risk of pulmonary complications (StEP-COMPAC definition) following major abdominal surgery was poorly described by existing prognostication tools. To improve surgical safety during the COVID-19 pandemic recovery and beyond, novel risk stratification tools are required.

FUNDING

British Journal of Surgery Society.

Deeper may not be better: relationship between catheter dysfunction and location of the catheter tip in right-sided tunnelled haemodialysis catheters

AIM

To examine the relationship between catheter tip location and catheter dysfunction in the context of tunnelled central venous catheters (CVCs) for haemodialysis.

MATERIALS AND METHODS

This was a retrospective study of 993 haemodialysis patients who underwent insertion of tunnelled CVCs of step-tip design via the right internal jugular vein (IJV). Based on intra-procedural radiographs, the catheter tip was characterised as being in the superior vena cava (SVC), cavo-atrial junction (CAJ), or deep right atrium (DRA). Patients were tracked for 90 days post-procedure for complications resulting in catheter replacement, and these were compared between cohorts. Statistical analysis was performed with Pearson's chi-square and Fisher's exact tests for categorical variables and two-sample t-test and one-way analysis of variance (ANOVA) for continuous variables.

RESULTS

Ninety-five patients (9.6%) experienced catheter dysfunction necessitating replacement within 90 days of insertion. Tip location in SVC was associated with lower occurrence of catheter dysfunction (1.9%) as compared with the CAJ (8%) and DRA (11%; p=0.049). Catheter replacement due to other complications (catheter-associated bacteraemia, cuff dislodgement, exit-site infection, external catheter damage) showed no statistically significant relation to location of the CVC tip.

CONCLUSION

When utilising tunnelled CVCs with a step-tip design inserted via the right IJV, location of the catheter tip in the SVC is associated with reduced occurrence of catheter dysfunction as compared to either the CAJ or DRA.

1015 AN OBSERVATIONAL STUDY OF THE CORRELATION OF FRAILTY SEVERITY WITH MENTAL HEALTH

Introduction

The eFI (electronic Frailty Index) is used to assess the severity of frailty in elderly frail patients using a cumulative deficit model based on routine interactions with their GP. Frailty is associated with an increased risk of falls, reduced mobility, hospitalisations, disability and death.

Method

Patients were selected for annual frailty assessments by searching the electronic clinical system (SystmOne) using the eFI tool. Patients were assessed using the Comprehensive Geriatric Assessment (CGA) framework. In addition, all patients were screened for coexisting anxiety and depression using the Patient Health Questionnaire (PHQ-9) and Generalised Anxiety Disorder (GAD-7) questionnaire.

Results

Of the 118 patients who ranged from mild to severe frailty, we found there was a positive correlation of the frailty severity eFI scores with increased rates of anxiety and depression evidenced by higher scores on the PHQ-9 and GAD-7 scoring tools. We found a positive correlation of the eFI with the PHQ-9 depression scores of (r = 0.819 p &lt; 0.001). Within the same data set, we found correlation coefficients of eFI and anxiety GAD-7 scores (r = 0.651 p &lt; 0.001). Increasing frailty was found to be associated with a higher rate of depression and anxiety.

Conclusion

We found in this study higher (eFI) electronic frailty indices are associated with worsening physical impairment and higher rates of anxiety and depression. We would recommend annual frailty assessments in patients with high electronic frailty indices and this should include screening for mental health deterioration. Early detection of deterioration will enable patient centered supportive measures and targeted treatment strategies. Health maintenance programs should ensure patient centered holistic assessment of both physical and mental health needs for early identification to avoid deterioration of both physical and mental health.

Appendiceal diverticulum masquerading as acute appendicitis

Appendiceal diverticula present as rare clinical finding and are most confused with acute appendicitis. A 65-year-old female was presented to our surgical service after 1 day of right lower quadrant abdominal pain and a computed tomography evaluation, read as a diagnosis of acute appendicitis. Due to the location and quality of pain and intraoperative findings acute appendicitis was our preliminary diagnosis. Follow up with histopathology confirmed acute inflammation of an appendiceal diverticulum. With discordance in original diagnosis from final pathological evaluation, we suggest appendiceal diverticula as an important differential to consider in patients of similar clinical presentation. Surgical treatment with appendectomy and final histological diagnosis are essential in the proper treatment of this rare clinical finding.

An observational study of the correlation of efi severity with depression

Introduction

Patients with high fraility indices experience poor mental health due to multiple co morbidity and social isolation.

Objectives

This was a retrospective observational analysis that studied the correlation of Electronic frailty indices and GAD scores with Depression scores in a rural population.

Methods

An annual frailty assessment is offered to elderly patients and we screen routinely for anxiety and depression using the PHQ-9 score and GAD score. This was an observational study examining the correlation of the Electronic Frailty Indices (EFI) depression and anxiety scores.

Results

Of the 118 patients ranging from mild to severe frailty we found a positive correlation of the EFI with the Depression and anxiety scores. Within the data set, the correlation coefficient of EFI scores and PHQ 9 scores was found to be 0.819. Similarly within the same data set we found a correlation coefficient of EFI and GDS scores of 0.651. The higher the EFI the greater was the scale of dependency and comorbidity and this correlation was consistent across the data set with depression and anxiety. We believe physical impairment, loss of independence and social isolation cognitive decline contribute to loss of self-esteem.

Conclusions

Our study found a positive correlation between frailty severity based on EFI scores and depression and anxiety severity. Early detection in deterioration of mental health will enable supportive measures and targeted treatment strategies. Our study shows the strong correlation of EFI severity scores with worse mental health.

Disclosure

No significant relationships.

Clinical outcomes following surgical management of insertional Achilles tendinopathy using a double-row suture bridge technique with mean two-year follow-up

BACKGROUND

The clinical outcomes following surgical management of insertional Achilles tendinopathy (IAT) vary depending on the surgical technique used to reattach the Achilles tendon following debridement. The aim of this study was to investigate the clinical outcomes of patients with IAT who underwent surgical management with a double-row suture bridge technique used to reattach the Achilles tendon.

METHODS

A retrospective review of consecutive patients diagnosed with IAT, who underwent surgical management utilising a double-row suture bridge technique (Arthex Speedbridge), and a minimum of 3-month follow-up were included. The primary outcome was the Manchester-Oxford Foot Questionnaire (MOXFQ) Index score which is a patient reported outcome measure (PROM). Secondary outcomes included EuroQol EQ-5D-5L health-related quality of life PROM and complication rates.

RESULTS

Between July 2013 and June 2020, 50 consecutive patients (23 male; 27 female) were included. The mean age (± standard deviation) was 52.3 ± 11.3 (range 29.0-84.3). Pre- and post-operative PROM data were available for all cases. The mean follow-up was 2.4 ± 1.9 years. The MOXFQ Index score improved from 48.5 to 12.4 (p < 0.01), EQ-5D-5L improved from 2.7 ± 0.46 to 1.2 ± 0.37 (p < 0.01), and EQ-VAS improved from 48.0 ± 18.4 to 84.1 ± 12.6 (p < 0.01). Four patients had complications which were of minimal clinical relevance and caused no deviation from routine recovery. There were no cases of tendon rupture.

CONCLUSION

This study has demonstrated that surgical management of IAT is safe and effective with clinical improvement in both clinical and general health-related quality of life outcome PROMs.

LEVEL OF EVIDENCE

IV.

Foot care knowledge and self-care practices among diabetic patients in Penang: A primary care study

INTRODUCTION

In Malaysia, the prevalence of diabetes mellitus has been increasing annually, currently affecting 18.3% of the population. Diabetic foot ulcer, a common complication of diabetes, is associated with high morbidity and mortality, consequently increasing health care expenditure. A previous study showed that foot care knowledge and foot self-care practices help to reduce the development of ulcers.1,2 This study aims to identify the level of foot care knowledge and self-care practices among diabetic patients in the primary care setting.

OBJECTIVE

This study was to determine the level of foot care knowledge and foot self-care practices among diabetic patients in the primary care setting in Penang Island and its determinants and the correlation between level of foot care knowledge and self-care practices among diabetic patients.

MATERIAL AND METHODS

A cross sectional study was performed on 311 diabetic patients who were registered to two government health clinics in Penang. Information regarding respondents' demographic status, foot care knowledge, and foot self-care practices were gathered using a self-administered questionnaire. Data were analysed using the Statistical Package for the Social Sciences (SPSS) 22. The Mann-Whitney U test and Kruskal-Wallis test were applied to the analysis. Multiple linear regression was performed to identify the determinants. Correlation between knowledge and self-care practice was determined using the linear regression model.

RESULTS

One hundred and sixty-five (53.1%) respondents achieved good knowledge scores and 196 respondents (63%) achieved good self-care practice scores. The median age of respondents was 61 years, who were mostly females (56.6%), Malays (41.2%), and unemployed (48.6%). Median HbA1c level was 7.5%, and 42.8% of respondents had diabetes for 5 to 10 years. Lowest scores for knowledge and self-care practices were observed in foot skin care questions. Formal foot care education was found to be a significant predictor of foot care knowledge (p<0.05, 95% CI -1.102, -0.098). Foot care knowledge was significantly and positively correlated with foot self-care practices (p<0.001, 95% CI 0.548, 0.727).

CONCLUSION

Foot care knowledge has significant positive correlation with foot self-care practices. Empowering diabetic patients with foot care knowledge may lead to significantly better foot self-care practices.

A250 NUTRISUP-PPN; PILOT RANDOMIZED CONTROL TRIAL OF ORAL AND PARENTERAL NUTRITION IN MALNOURISHED HOSPITALIZED PATIENTS

Background

Hospitalized malnourished patients experience poor outcomes. Despite this, health care practitioners are poor in identifying, monitoring and treating hospital malnutrition.

Aims

Our study determined the feasibility of a novel nutrition care pathway which both rapidly identifies and treats malnourished medical inpatients accounting for the obstacles for nutritional optimization by utilizing both peripheral parental nutrition (PPN) followed by oral nutritional supplementation (ONS) on a composite outcome of 30 day readmission, mortality and continued admission, as well other important clinical and nutritional outcomes. The study was registered under ClinicalTrials.gov Identifier no. NCT02632630

Methods

NutriSUP-PPN was a 2x2 factorial pilot randomized trial. In two large Canadian hospitals, we recruited 100 adult patients &gt; 18 years, &lt; 48 hours from admission to a general medicine ward who were moderately or severely malnourished. Patients received: 1. PPN for 5 days and then enhanced ONS until 30 days post randomization; 2. PPN for 5 days and then standard ONS until 30 days; 3. Standard care for intravenous (IV) fluid administration for 5 days and then enhanced ONS until 30 days; 4. Standard care for IV fluid administration for 5 days and standard ONS until 30 days.

Results

There was no significant differences between a composite outcome of 30 day readmission, continued admission or mortality between any interventional group and control. We did however note a trend in the PPN + ONS arm where only 4/22 patients versus 10/24 patients (p=0.16) in the control (no PPN, no enhanced ONS) experienced an adverse outcome which was largely driven by a reduction of readmission in the ONS + PPN arm We demonstrated feasibility in recruitment, adherence to protocol, and safety. The incidence of sepsis was greater in the PPN arm compared to control (15.5% versus 4.2%) but was not statistically significant. Improvement in nutritional status for interventional arms were not significant compared to control. However, there was a trend of improvement in preventing decline of nutritional status in both the enhanced ONS arm and PPN + enhanced ONS arm.

Conclusions

There are signals in our data, which suggest that the combination of PPN with ONS may improve both clinical and nutritional outcomes compared to PPN or ONS alone. We posit that a large, multi-center, definitive randomized control trial is now justified to determine if PPN for up to 5 days along with 30 days of ONS, versus standard of care, will improve a composite outcome of death, continued admission, and readmission at 30 days.

Funding Agencies

CAGAMOSO

Serafini R, Lakhtakia S, Valliani AA, Warburton AJ, Patel A, Zhou D, Sklar B, Chelnis J, Elahi E. Portable hardware & software technologies for addressing ophthalmic health disparities: A systematic review

Vision impairment continues to be a major global problem, as the WHO estimates 2.2 billion people struggling with vision loss or blindness. One billion of these cases, however, can be prevented by expanding diagnostic capabilities. Direct global healthcare costs associated with these conditions totaled $255 billion in 2010, with a rapid upward projection to $294 billion in 2020. Accordingly, WHO proposed 2030 targets to enhance integration and patient-centered vision care by expanding refractive error and cataract worldwide coverage. Due to the limitations in cost and portability of adapted vision screening models, there is a clear need for new, more accessible vision testing tools in vision care. This comparative, systematic review highlights the need for new ophthalmic equipment and approaches while looking at existing and emerging technologies that could expand the capacity for disease identification and access to diagnostic tools. Specifically, the review focuses on portable hardware- and software-centered strategies that can be deployed in remote locations for detection of ophthalmic conditions and refractive error. Advancements in portable hardware, automated software screening tools, and big data-centric analytics, including machine learning, may provide an avenue for improving ophthalmic healthcare.

Endovascular Chemotherapy: Selective Targeting for Brain Cancer

Establishing an effective and robust management option for brain cancers has proven to bean elusive challenge for the fields of neurosurgery and neuro-oncology. Despite decades of research efforts to improve treatment outcomes and increase patient survivability, brain cancer remains among the most fatal of all cancer classes. A significant barrier to this endeavor is the blood-brain barrier, a major protective border for brain tissue that primarily precludes the optimal delivery of chemotherapeutic drugs to the patient's brain circulation through tight junction formations and selective transporter proteins. This issue is often compounded by tumor location, particularly in inoperable regions near functional brain parenchyma. These obstacles necessitate the development of selectively targeted delivery of chemotherapeutic agents, such as endovascular super-selective intra-arterial injections. Recent experimental studies demonstrate the effectiveness of focused ultrasound to unseal the blood-brain barrier selectively and reversibly. Together, these new technologies can be leveraged to circumvent the limited permeability of the blood-brain barrier, thus improving drug delivery to tumoral locations and potentially enabling a more effective treatment alternative to surgical resection. This review attempts to place into context the necessity of these newer selective chemotherapeutic modalities by briefly highlighting commonly encountered brain cancers and explaining the prominent challenges that face chemotherapy delivery, as well as describing the current preclinical and clinical progress in the development of facilitatory focused ultrasound with selective endovascular chemotherapy.

Absence of clinical benefit of FDG PET-CT in staging T1 part-solid lung adenocarcinoma

AIM

To assess the rates of nodal and metastatic disease and change in management when staging part-solid T1 lung adenocarcinomas using integrated 2-[¹⁸F]-fluoro-2-deoxy-d-glucose (FDG) positron-emission tomography (PET)-computed tomography (CT) in a UK population.

MATERIALS AND METHODS

This was a retrospective review of PET-CT examinations performed to stage radiologically suspected T1 part-solid lung adenocarcinoma (n=58) from two different centres. Rates of detection of nodal and metastatic disease, change in management, and final patient outcome were recorded.

RESULTS

PET-CT changed the stage in one patient from N0 to N1. It did not change final management in any patient.

CONCLUSIONS

In this UK population, PET-CT had minimal additional diagnostic benefit in staging patients with T1 part-solid lung adenocarcinoma. Especially given its cost, the inclusion of PET-CT for this indication in guidelines should be reviewed.

Estrogen-related Receptor Alpha (ERRα) is Required for PGC-1α-dependent Gene Expression in the Mouse Brain

Deficiency in peroxisome proliferator-activated receptor gamma coactivator 1-alpha. (PGC-1α) expression or function is implicated in numerous neurological and psychiatric disorders. PGC-1α is required for the expression of genes involved in synchronous neurotransmitter release, axonal integrity, and metabolism, especially in parvalbumin-positive interneurons. As a transcriptional coactivator, PGC-1α requires transcription factors to specify cell-type-specific gene programs; while much is known about these factors in peripheral tissues, it is unclear if PGC-1α utilizes these same factors in neurons. Here, we identified putative transcription factors controlling PGC-1α-dependent gene expression in the brain using bioinformatics and then validated the role of the top candidate in a knockout mouse model. We transcriptionally profiled cells overexpressing PGC-1α and searched for over-represented binding motifs in the promoters of upregulated genes. Binding sites of the estrogen-related receptor (ERR) family of transcription factors were enriched, and blockade of ERRα attenuated PGC-1α-mediated induction of mitochondrial and synaptic genes in cell culture. Localization in the mouse brain revealed enrichment of ERRα expression in parvalbumin-expressing neurons with tight correlation of expression with PGC-1α across brain regions. In ERRα null mice, PGC-1α-dependent genes were reduced in multiple regions, including neocortex, hippocampus, and cerebellum, though not to the extent observed in PGC-1α null mice. Behavioral assessment revealed ambulatory hyperactivity in response to amphetamine and impairments in sensorimotor gating without the overt motor impairment characteristic of PGC-1α null mice. These data suggest that ERRα is required for normal levels of expression of PGC-1α-dependent genes in neurons but that additional factors may be involved in their regulation.