Intravenous tranexamic acid and lower limb arthroplasty-a randomised controlled feasibility study

Tranexamic acid (TA) is widely reported to reduce bleeding and the risk of blood transfusion in patients undergoing lower limb arthroplasty. No study in this setting has had adequate power to examine for the effect of TA on either uncommon, but clinically important, adverse events or patient-centric endpoints. A large randomised controlled trial (RCT) is required to address these questions. As a preliminary feasibility study, we conducted an investigator-initiated, prospective, randomised, double blind placebo-controlled trial in 140 patients, aged 45 years or older, undergoing elective primary or revision hip or knee joint replacement. Subjects were randomised to receive intravenous (IV) TA or a placebo. The primary endpoints were the proportion of patients receiving allogenic blood transfusion and the feasibility of extending our trial methodology to a large trial of TA in this population. Secondary endpoints included a range of adverse clinical and surgical events as well as several patient-centric questionnaires. Red blood cell transfusion occurred in 15% of all patients prior to discharge from hospital. Transfusion rates were significantly different between the TA and placebo groups (8.5% versus 21.7%, <i>P</i>=0.03). Three out of four feasibility endpoints were met, with recruitment being slower than expected. No significant differences were seen between groups in the secondary endpoints. Despite a lower rate of transfusion than that widely reported, IV TA reduced transfusion in patients undergoing lower limb arthroplasty. Our trial methodology would be feasible in the setting of a large multicentre study to investigate whether TA is safe and reduces bleeding in lower limb arthroplasty.

Rapid and reversible impairment of episodic memory by a high-fat diet in mice

Alzheimer’s disease is a leading cause of morbidity and mortality with no cure and only limited treatment available. Obesity and type 2 diabetes are positively associated with the development of premature cognitive decline and Alzheimer’s disease, linking diet with these conditions. Here we demonstrate that in mice episodic memory, together with spatial and contextual associative memory, is compromised after only one day of high-fat diet. However, object memory remains intact. This shows not only a more rapid effect than previously reported but also that more complex memories are at higher risk of being compromised by a high-fat diet. In addition, we show that these memory deficits are rapidly reversed by switching mice from a high-fat diet back to a low-fat diet. These findings have important implications for the contribution of nutrition to the development of cognitive decline and Alzheimer’s disease.

The prevalence, risk factors predicting injury and the severity of injuries sustained during competition in professional mixed martial arts in Africa

Background: Professional mixed martial arts (MMA) has gained international popularity. No African-based studies have reported the prevalence or severity of injuries, risk factors associated with injuries or return-to-play (RTP) time. Objectives: To determine the prevalence of injuries and associated risk factors, as well as severity of injuries sustained by professional male MMA athletes competing at the Extreme Fighting Championships Africa (EFC Africa) from 2010 to 2014.Methods: Permission to do the study and the medical records of all professional events (2010 – 2014) were obtained from EFC Africa. Data were obtained from 173 male competitors aged 18 to 44 years, who had participated in 300 professional MMA fights. Results from this prospective cohort study were compared to a similar study done in the United States of America (USA). An injury was defined as any damage to an athlete’s body that needed the attention of the ringside physician. Statistical analyses included descriptive statistics and a stepwise logistic regression. Odds of an injury were predicted with six independent variables: fight outcome, age, weight division, number of fights, injuries in the preceding fight and years of fighter experience.Results: Head, face and neck injuries were most common (22%), followed by traumatic brain injuries (knockouts) (6%). Losing a fight was a significant predictor of injury when using the stepwise logistic regression model (p=0.040). The odds ratio indicated that a preceding fight injury almost doubled the risk of injury in the following fight (OR 1.91; p= 0.163). Traumatic brain injuries (TBIs) in this study of African-based competitions (6%) were substantially higher than reported in the American study (1.8%).Conclusion: Head, neck and face injuries are common in African fighters. The high rate of TBIs in African competition compared to the USA study is concerning. This could reflect superior refereeing in the USA group, as fights may be ended sooner by stoppage. Further investigation of injury trends and preventative measures should be studied to reduce the incidence of injuries during African competitions.

The use of negative pressure wave treatment in athlete recovery

Background: Athletes need to recover fully to maximise performance in competitive sport. Athletes who replenish more quickly and more efficiently are able to train harder and more intensely. Elite athletes subjectively report positive results using lower body negative pressure (LBNP) treatment as an alternate method for rapid recovery, restoring and improving their impaired physical state. Objective data on the efficacy are lacking.Objectives: To investigate the effect of intermittent vacuum therapy on accelerating acute recovery following an athlete’s normal daily training schedule of strenuous exercise. Objective measurements of biological markers of muscular fatigue were used to assess recovery.Methods: Twenty-two male cricket players in a randomised cross-over study were divided into a treatment and control group respectively. Following a one-hour high-intensity gym session, the treatment group received three 30-minute LBNP exposure sessions over three consecutive days (0, 24 and 48 hours). Blood lactate and creatine kinase biomarkers were collected to measure the recovery process. After 14 days groups were crossed over and the trial repeated.Results: Heart rate and blood pressure decreased noticeably during treatment, reverting to baseline levels after treatment. Lactate concentrations decreased in both groups after exercise termination; significantly more in the treatment (0.57±0.23 mmol/l) than control group (0.78±0.22 mmol/l), p<0.001). Creatine kinase (CK) was similar in both groups. Athletes’ subjective assessments of recovery rated moderately high.Conclusion: LBNP therapy applied as treatment during routine schedule may have a systemic effect in lowering serum lactate levels, but not CK levels. Enhanced recovery of athletes is still unconfirmed.

107 RESEARCH PRIORITIES FOR SAFE SANITARY TRADE OF EMBRYO AND SEMEN

Embryo transfer and artificial insemination are utilised nationally and internationally for the introduction, improvement, and preservation of livestock genetics. Embryos present a lower risk of infectious disease transmission than do live animals. In order to maintain the sanitary security and to facilitate the trade of embryos and semen worldwide, the Health and Scientific Advisory Committee of the International Embryo Technology Society designed, developed, and conducted a survey to determine research priority. The survey questionnaire was sent to 32 government representatives and 76 embryo transfer and artificial insemination industry representatives around the world to countries where artificial breeding industries are active and well developed. A total of 16 answers were received, 9/32 (28%) from government representatives and 7/76 (9%) from industry representatives. The global feedback was 15%. The survey indicated that, in terms of research priority, embryos and semen were equally important. With regards to embryo research priorities, the survey results ranked in vitro-produced embryos research as the most important, followed by in vitro-derived embryos, and then oocytes. Apart from scrapie for embryos and Campylobacteriosis for semen, research priorities were similar for the major pathogens of embryos and semen, in particular, bovine viral diarrhoea and paratuberculosis (Johne’s disease; Table 1). Emerging or less common diseases were not forgotten. Other diseases suggested but not listed in Table 1 included bluetongue, foot and mouth disease, lentivirus, arbovirus, bovine tuberculosis, porcine epidemic diarrhoea, porcine reproductive and respiratory syndrome, African swine fever, and ovine pulmonary adenocarcinoma (Jaagsiekte). The survey highlighted the need to focus research largely on ruminant species (Table 1). Other issues identified by the survey included (i) alternative or indirect processes for determining the sanitary quality of in vitro-produced embryo as for in vitro-derived embryos, including standardized testing of discarded oocytes or testing culture media for pathogens with validated PCR techniques, (ii) safe sanitary techniques for the perforation of the zona pellucida for biopsy, for pre-implantation genetics and for diagnostic purposes, (iii) recommendations for international trade in embryos or semen originating from vaccinated donors, and (iv) use of biologicals for disinfecting embryos during washing procedures. Table 1. Answers (%) to the questions: Which pathogens (species) represent the most urgent research need? (answers with results <5% are not listed)

Severe Bradycardia Following Initiation of Low-Dose Olanzapine in A Patient with Anorexia Nervosa

BACKGROUND: Low-dose Olanzapine has been used clinically for over a decade in anorexia nervosa (AN) patients failing standard treatment in order to decrease anxiety and facilitate weight gain. While Olanzapine has been generally well tolerated, large scale data regarding safety and side-effects in AN patients is lacking.

OBJECTIVES: To examine possible association between severe bradycar-dia and Olanzapine use in AN patients.

DESIGN/METHODS: Case study and literature review.

RESULTS: We present a case of severe bradycardia (HR 18) following initiation of low-dose Olanzapine in a 16 year old female admitted to our inpatient ward with AN and bradycardia during sleep.To our best knowl-edgeno other case studies of severe bradycardia in AN patients treated with Olanzapine have been published to date.We relate our case to findings from available literature that examines potential association between bradycardia and Olanzapine. We point to challenges with obtaining larger scale data on Olanzapine safety and side-effects in AN patients.

CONCLUSION: There areinherent cardiac risks associated with treatment of AN patients. Existing literature in patients with diagnosis other than AN suggests there may be inter-individual differences in pharmacoki-netics of Olanzapine and that bradycardia may be a possible adverse effect of Olanzapine even at a low dose. Caution should be used in initiating Olanzapine in AN patients with baseline bradycardia.

Condition-related predictors of successful transition from paediatric to adult care among adolescents with Type 1 diabetes

AIMS

To describe patient attendance for adult treatment after completion by young people of a structured Diabetes Transition Clinic and to identify the predictors of non-attendance at adult clinics by young people with Type 1 diabetes transitioning from paediatric care.

METHODS

Young people with Type 1 diabetes were consecutively enrolled on a Diabetes Transition Clinic programme at a Canadian paediatric teaching hospital, beginning in December 2007. Data from clinical interviews completed by an adolescent medicine specialist and an adult endocrinologist were prospectively collected at the Diabetes Transition Clinic visit in the patient's 18(th) year, before he/she was transferred at age 18 years to the adult clinic and at the first adult clinic visit.

RESULTS

As of June 2011, 136 young people participating in the Diabetes Transition Clinic programme had been discharged from paediatric care at least 1 year earlier. Of these, 43 participants were lost to follow-up. Loss to follow-up was more frequent among: those who were diagnosed with diabetes before the age of 12 years; those who were taking insulin twice or three times daily rather than by pump or multiple daily injections; those who had higher HbA1c levels; those who had fewer diabetes physician visits in the year preceding the Diabetes Transition Clinic visit; and those who did not ask questions at the Diabetes Transition Clinic visit.

CONCLUSIONS

Several factors easily ascertained at a clinical encounter before transition can predict the likelihood of attendance in adult care, including age at diagnosis, mode of insulin administration, frequency of physician visits, and questions asked by patients during a transition visit.

Development and validation of a generic scale for use in transition programmes to measure self-management skills in adolescents with chronic health conditions: the TRANSITION-Q

AIM

To develop a generic self-management skills scale for use with adolescents diagnosed with a chronic health condition who are aged 12 to 18 years.

BACKGROUND

There is a lack of methodologically sound scales for healthcare teams to use to measure self-management skills in adolescents with chronic conditions transitioning to adult care.

METHODS

Adolescents aged 12 to 18 years with a broad range of chronic health conditions, including neurodevelopmental conditions, were recruited from May to August 2013 from nine outpatient clinics at McMaster Children's Hospital (Canada). Thirty-two participated in a cognitive interview, and 337 completed a questionnaire booklet. Interviews were used to develop the TRANSITION-Q. Rasch measurement theory (RMT) analysis was used to identify items that represent the best indicators of self-management skills. Traditional psychometric tests of measurement performance were also conducted.

RESULTS

The response rate was 92% (32/32 cognitive; 337/371 field test). RMT analysis resulted in a 14-item scale with three response options. The overall fit of the observed data to that expected by the Rasch model was non-significant, providing support that this new scale measured a unidimensional construct. Other tests supported the scale as scientifically sound, e.g. Person Separation Index = 0.82; good item fit statistics; no differential item function by age or gender; low residual correlations between items; Cronbach's alpha = 0.85; test-retest reliability = 0.90; and tests of construct validity that showed, as hypothesized, fewer skills in younger participants and in participants who required assistance to complete the scale. Finally, participants who agreed they are ready to transfer to adult healthcare reported higher TRANSITION-Q scores than did participants who disagreed.

CONCLUSIONS

The TRANSITION-Q is a short, clinically meaningful and psychometrically sound scale. This generic scale can be used in research and in paediatric and adolescent clinics to help evaluate readiness for transition.

Immunomodulatory effects of H.P. Acthar Gel on B cell development in the NZB/W F1 mouse model of systemic lupus erythematosus

H.P. Acthar Gel® (Acthar) is a highly purified repository gel preparation of adrenocorticotropic hormone (ACTH1-39), a melanocortin peptide that can bind and activate specific receptors expressed on a range of systemic lupus erythematosus (SLE)-relevant target cells and tissues. This study was performed to evaluate the effects of Acthar in a mouse model of SLE, using an F1 hybrid of the New Zealand Black and New Zealand White strains (NZB/W F1). Twenty-eight week old NZB/W F1 mice with established autoimmune disease were treated with Acthar, Placebo Gel (Placebo), or prednisolone and monitored for 19 weeks. Outcomes assessed included disease severity (severe proteinuria, ≥ 20% body weight loss, or prostration), measurement of serial serum autoantibody titers, terminal spleen immunophenotyping, and evaluation of renal histopathology. Acthar treatment was linked with evidence of altered B cell differentiation and development, manifested by a significant reduction in splenic B cell follicular and germinal center cells, and decreased levels of circulating total and anti-double-stranded DNA (IgM, IgG, and IgG2a) autoantibodies as compared with Placebo. Additionally, Acthar treatment resulted in a significant decrease of proteinuria, reduced renal lymphocyte infiltration, and attenuation of glomerular immune complex deposition. These data suggest that Acthar diminished pathogenic autoimmune responses in the spleen, peripheral blood, and kidney of NZB/W F1 mice. This is the first preclinical evidence demonstrating Acthar's potential immunomodulatory activity and efficacy in a murine model of systemic lupus erythematosus.

Long-term exposure to a high-fat diet results in the development of glucose intolerance and insulin resistance in interleukin-1 receptor I-deficient mice

Emerging evidence has demonstrated that saturated fatty acids prime pro-IL-1β production and inflammasome-mediated IL-1β activation is critical in obesity-associated insulin resistance (IR). Nonetheless, IL-1 receptor I-deficient (IL-1RI(-/-)) mice develop mature-onset obesity despite consuming a low-fat diet (LFD). With this apparent contradiction, the present study evaluated whether IL-1RI(-/-) mice were protected against long-term (6 mo) high-fat diet (HFD)-induced IR. Male wild-type and IL-1RI(-/-) mice were fed LFD or HFD for 3 or 6 mo, and glucose and insulin tolerance tests were performed. Adipose insulin sensitivity, cytokine profiles, and adipocyte morphology were assessed. The adipogenic potential of stromal vascular fraction was determined. Hepatic lipid accumulation and insulin sensitivity were characterized. IL-1RI(-/-) mice developed glucose intolerance and IR after 6 mo HFD compared with 3 mo HFD, coincident with enhanced weight gain, hyperinsulinemia, and hyperleptinemia. The aggravated IR phenotype was associated with loss of adipose functionality, switch from adipocyte hyperplasia to hypertrophy and hepatosteatosis. Induction of adipogenic genes was reduced in IL-1RI(-/-) preadipocytes after 6 mo HFD compared with 3 mo HFD. Obese LFD-IL-1RI(-/-) mice exhibited preserved metabolic health. IL-1RI(-/-) mice develop glucose intolerance and IR after 6 mo HFD intervention. While mature-onset obesity is evident in LFD-IL-1RI(-/-) mice, the additional metabolic insult of HFD was required to drive adipose inflammation and systemic IR. These findings indicate an important interaction between dietary fat and IL-1, relevant to optimal metabolic health.

The relationship between patient data and pooled clinical management decisions

A strong relationship between patient data and preoperative clinical decisions could potentially be used to support clinical decisions in preoperative management. The aim of this exploratory study was to determine the relationship between key patient data and pooled clinical opinions on management. In a previous study, panels of anaesthetists compared the quality of computer-assisted patient health assessments with outpatient consultations and made decisions on the need for preoperative tests, no preoperative outpatient assessment, possible postoperative intensive care unit/high dependency unit requirements and aspiration prophylaxis. In the current study, the relationship between patient data and these decisions was examined using binomial logistic regression analysis. Backward stepwise regression was used to identify independent predictors of each decision (at P >0.15), which were then incorporated into a predictive model. The number of factors related to each decision varied: blood picture (four factors), biochemistry (six factors), coagulation studies (three factors), electrocardiography (eight factors), chest X-ray (seven factors), preoperative outpatient assessment (17 factors), intensive care unit requirement (eight factors) and aspiration prophylaxis (one factor). The factor types also varied, but included surgical complexity, age, gender, number of medications or comorbidities, body mass index, hypertension, central nervous system condition, heart disease, sleep apnoea, smoking, persistent pain and stroke. Models based on these relationships usually demonstrated good sensitivity and specificity, with receiver operating characteristics in the following areas under curve: blood picture (0.75), biochemistry (0.86), coagulation studies (0.71), electrocardiography (0.90), chest X-ray (0.85), outpatient assessment (0.85), postoperative intensive care unit requirement (0.88) and aspiration prophylaxis (0.85). These initial results suggest modelling of patient data may have utility supporting clinicians' preoperative decisions.